Profit Was Paramount, Former Workers Say
By Scott Higham and Sewell Chan
Washington Post Staff Writers
Tuesday, July 15, 2003; Page A01
On the edge of Georgetown near the banks of the Potomac River, surrounded by leafy trees and quiet residential sidewalks, stands an unassuming brown-brick building. Few passersby know that this is Riverside Hospital, the largest psychiatric facility for troubled children in the District.
Behind this blandly pleasant facade, some unpleasant incidents have occurred, according to reports by the city's child protection agency.
In June 2002, a 12-year-old boy was sexually abused by his 15-year-old roommate after Riverside employees ignored his expressed fears. In December, a 13-year-old girl performed sexual favors for an employee in exchange for snacks, carryout food and help in escaping. In January, an employee threw a 13-year-old boy against a wall and slammed him to the floor.
The same month the 12-year-old was abused, city monitors examining treatment and conditions at Riverside said they were concerned by the frequent use of psychotropic drugs to control behavior, poor upkeep inside the facility, staff turnover and a failure to adequately supervise the children.
"Protection and safety continue to be issues of question at Riverside Hospital," said the officials from the D.C. Child and Family Services Agency.
Their findings were part of a seven-year-long chain of critical city and federal inspection reports. Once perceived as a savior for the District's foster children and juveniles, Riverside has been beset by criticisms of its care and allegations that it kept children for unneeded treatment, according to government and hospital records and interviews with former employees, social workers, relatives and attorneys for the children.
The private, for-profit facility consists of a 96-bed unit offering short-term acute care for profoundly disturbed children at about $700 per day, and a 54-bed residential treatment center providing long-term counseling and medication at $250 per day. Founded by a psychiatrist in 1995, Riverside is run by his close associates and surviving family members.
In addition to the reports of health care regulators and Medicaid auditors, who have cited numerous safety problems and incidents in which children were kept longer than necessary, former employees interviewed for this article added a host of allegations.
Two former employees, including the former associate administrator, said that children were admitted to the locked-down facility even though they didn't appear to have serious psychiatric problems. A parent and a court-appointed mentor said that it was hard to get the hospital to discharge two particular children, even when they appeared to have improved.
Medical charts and other documents were hastily reconstructed in advance of health care inspections, according to the former administrator and a former medical records transcriber.
Hospital employees were offered commissions -- 3 percent to 4 percent of the medical bills -- to recruit children to fill beds, said the former administrator and a former hospital community outreach worker.
"We were making money," said Deborah Lockhart, who started at Riverside from its opening in 1995 and resigned in 2000 as its associate administrator and director of human resources. "That was always the priority: Let's do whatever we can to ensure that the money comes in."
Hospital administrators deny the allegations.
"It's absolutely untrue," said Barbara Groves, Riverside's director of development and community outreach, who has worked at the hospital since it opened.
Groves and other hospital officials said they are devoted to helping the children under their care, in some instances treating them for free when their parents or Medicaid could not pay. Groves said Riverside has yet to turn a profit. Hospital officials acknowledged that Riverside has had problems in the past, but they said the relatively young institution is making progress and has done well on recent inspections.
While Child and Family Services monitors have continued to express concerns, the most recent inspection of Riverside by federal health care regulators, in May, documented fewer violations than in years past.
"We do great work with a lot of very difficult kids, kids who have been so traumatized and abused that it's horrific people can actually treat children this way," said Michael Goodman, Riverside's administrator. "And I know we do a very good job in a very tough environment, in a very heavily regulated environment. You can't sneeze here without getting somebody to call you and say, 'Why did you sneeze?' "
The hospital pointed to current employees, former and current city social services workers, a patient and a mother of a patient who spoke highly of the hospital's care. Cecilia Thomas, a youth mentor for the D.C. Department of Parks and Recreation, said she has referred four or five children to Riverside and all have done well. William Walker, a former counselor for the city's juvenile justice agency, said he also has referred children to Riverside.
"They are the only place that I know of in the Washington, D.C., area where I can get some relief for the insanity these children are going through," Walker said.
Phyllis Morgan, president of the Family Advocacy and Support Association, a group for parents of mentally ill children in the District, said her members have complained about treatment of children at Riverside. She said the city's decision in 2001 to close the children's unit at St. Elizabeths Hospital, the city-run psychiatric institution, has increased the District's dependence on Riverside.
"I've never been a proponent of Riverside," Morgan said. "I think when problems arise at Riverside, the city does not act on them. The city officials are afraid that Riverside will stop taking District children, and that means they will have to come up with another solution.
"Riverside could be part of the solution if Riverside was made to shape up," she added. "There would have to be a lot of changes at the hospital before I would recommend it."
City officials have varying views of Riverside. Last month, one said Riverside was doing well.
"It is not a facility we have had a lot of complaints and incidents at," said Denise S. Pope, head of the Health Regulation Administration, the arm of the D.C. Department of Health that oversees hospitals. "It is not one of our problem facilities."
Pope said she had not reviewed the reports on Riverside by Child and Family Services, and her agency inspects only Riverside's acute-care unit.
Olivia A. Golden, director of Child and Family Services, said she was troubled by the allegations of abuse that her monitors have been citing at Riverside.
"It makes us worry," Golden said recently. "We are concerned."
One D.C. Superior Court judge who sent children to Riverside in the past has almost entirely stopped. In an April 2002 letter to the city's child protection and mental health agencies, Judge Nan R. Shuker questioned whether it was a financial "conflict of interest" for the hospital to perform court-ordered evaluations of children who could end up receiving expensive long-term care in a Riverside bed.
She also raised concerns about supervision at Riverside, citing a case in which a girl obtained a razor and mutilated herself, and said the hospital never told her about the incident.
"I have gone from one of its biggest supporters to my current position, which is that, unless I have absolutely no alternative, I will not place a child from my calendar in this facility," Shuker wrote. "I think Riverside should be scrutinized and evaluated carefully to ensure that it is an adequate placement."
Hospital administrators and city officials said evaluations performed by Riverside doctors are reviewed by an outside medical panel before placement decisions are made.
"They don't always come back to Riverside," said Riverside's medical director, Sushma Jani.
The hospital was unable to provide a breakdown. But a spokeswoman for the D.C. Department of Mental Health said that at least 23 children were referred to Riverside for psychiatric evaluation from November to June. Of those, city officials found that five needed long-term in-patient treatment, and of those five, three ended up at Riverside.
'It Was Looking Good'
A decade ago, Jacob R. Fishman, a psychiatrist with a history of working with mentally disturbed children, approached the city with a proposal. He would take over a shuttered psychiatric hospital near Georgetown Day School on MacArthur Boulevard NW and transform it into a state-of-the-art psychiatric facility called Riverside Hospital. He said this would allow the District to stop sending so many foster children and juveniles to residential treatment centers in Georgia, Florida, Missouri and other states.
At the time, about 300 D.C. children were living in out-of-town centers, costing taxpayers about $25 million a year.
When Fishman had run a hospital in North Carolina, federal prosecutors accused him of defrauding a U.S. military health insurance program by double-billing for services and forging authorization signatures. In 1984, Fishman admitted that some of the claims filed by his hospital were false, and he agreed to pay $700,000 in reimbursements and civil fraud penalties.
Despite Fishman's past, some city officials were jubilant when he opened Riverside Hospital in 1995.
"Finally, we had something locally," said Shuker, the Superior Court judge. "It was looking good."
But Riverside soon faced criticism from federal and city health care regulators who said the facility neglected to complete medical charts and failed to report incidents of suspected sexual abuse and escapes. The regulators also said there were not enough workers to supervise the children, four of whom had attempted suicide within six months in 1996. Ten months later, in April 1997, federal regulators warned of "immediate jeopardy to the safety of residents." They moved to terminate Riverside from the Medicaid program -- a virtual death sentence for a facility that depends upon payments from the government's health insurance program.
In July 1997, the regulators decided to continue the hospital's Medicaid participation after Riverside promised to correct the problems. But in June 1998, the regulators said the problems had continued, and they again moved to revoke the hospital's Medicaid participation. At the same time, city inspectors were documenting escapes, an attempted suicide and a lack of adequate staff.
By August 1998, federal regulators had backed off their threat, and the city had allowed Riverside to operate under a restricted license that limited the number of patients to 45. The city also required the hospital to submit monthly staffing reports and report "unusual incidents" within 24 hours.
"We had very hard times in the beginning," said Groves, the hospital's director of development.
On Dec. 2, 1998, Fishman died of a heart attack. His son Marc, a psychiatrist, and his daughter Rebecca, a businesswoman who ran a nightclub, worked with others to keep Riverside afloat. Rebecca Fishman and Marc Fishman run American Healthcare Management LLC, the firm that oversees the hospital.
Rebecca Fishman and her brother Marc Fishman, vice president of American Healthcare Management. (File Photo)
Regulators began to identify a new problem: The hospital's in-house school, Riverside Academy, was failing to meet basic standards, even though the District was paying $150 a day per student.
According to inspection reports and interviews, children spent their time surfing the Internet and playing video games, checkers, dominoes and cards. Treatment and educational plans for the children were not created. Students sat in class in lawn chairs and were not given textbooks. Writing supplies were rare and homework nonexistent. Three principals came and went in one year. Children said in interviews with The Washington Post that conditions became so chaotic that they were able to slip out of class and have sex with each other in a nearby bathroom.
"These students appeared as if they were going to a party instead of school," a city monitor wrote in an April 2000 report, adding that the students seemed to be "overmedicated and undereducated."
Edwin Powell, principal of Riverside Academy from 1999 to 2000, said he tried to create a curriculum and secure more money for supplies for the children. He left the academy at the end of that school year.
"Despite my best efforts, I did not get a commitment from the hospital to develop a proper educational program for the kids," Powell said in a recent interview.
Riverside Academy's current principal, Leroy Woods Jr., said he has been trying to improve the school by developing individual curriculum plans for the children and adding computers and books in the classrooms. For the first time, he noted, the school won accreditation last September from the Middle States Association of Colleges and Schools, a nonprofit organization.
"We're very proud of that," Woods said.
Woods came to Riverside from the D.C. public school system, where he headed a special education facility called Eliot Center. On April 6, 2001, according to school system records, the city suspended Woods, with pay, for allegedly failing to report that one of his students had sexually abused another. By law, educators must report such incidents.
A month later, on May 14, while he was still on suspension, Woods began to work at Riverside -- and continued to collect his city salary, school system records show. School officials were angry.
"Your behavior is dishonest and inappropriate," Patricia Watkins Lattimore, the school system's human resources director, wrote to Woods on July 31. The school system demanded that Woods repay the $8,998 he collected from the city while he was on Riverside's payroll.
In a recent interview, Woods blamed subordinates for not reporting the abuse incident and said he filed an appeal at the time. His supervisor at Riverside said he stood by his principal.
"As a Riverside employee, he's been excellent," Goodman said. "He's done a stellar job."
'It Was Too Depressing'
As the hospital's associate administrator, Deborah Lockhart believed in Jacob Fishman's vision. After his death, Lockhart said, front-office officials focused more on profits and less on the care of children.
"We would admit children no matter what, and keep them no matter what," said Lockhart, who had worked at the hospital from the day it opened.
She and several other former employees said they were troubled by Riverside's handling of health care inspections. Regulators have long criticized Riverside for failing to maintain complete medical charts and other records relating to the children.
"There were all-night sessions when charts were reviewed and people were asked to complete them," she said. "In some instances, the kids were under watch, and the sheets monitoring them were incomplete, and they would just fill in the blanks."
Hospital officials denied the allegations. "That is absolutely not true," Groves said. "It is a common thing in hospitals, in any hospital, for the medical-records people to hound people to dot i's and cross t's. No charts were re-created here. I guarantee that."
The former employees said the incomplete paperwork included medical evaluations, progress notes, treatment plans and goals, discharge summaries and monitoring reports of children in the facility's isolation room.
"Doctors and social workers were supposed to fill out different areas of the medical files, but they were so understaffed they weren't doing it," said Elaine Alexander, who worked as a transcriber in Riverside's medical records division before resigning in 2001. "I'd have to go upstairs and track down the social workers and doctors."
She and the others said that some of the social workers and, occasionally, the doctors, were told to reconstruct from memory events in the children's charts, doing "whatever they had to do, by whatever means."
Lockhart said she was so unhappy with the hospital's direction that she stopped visiting children on the wards.
"I just couldn't go upstairs anymore," she said. "It was too depressing. I had to divorce myself." Near the end of the summer of 2000, she resigned.
Another veteran of the hospital's staff said she, too, believed the emphasis was on profits.
Terry Odum, who worked in community outreach for the hospital, said she was offered a commission of 3 percent to 4 percent of the medical bills of any children who could fill Riverside beds. Lockhart said she also was aware that the commissions were offered. Odum said she declined the offer. She eventually left in 1999 after four years on the job.
"We were supposed to be brokers for quality of care," she said in a recent interview. "But they believed in profits first and everything else second."
Groves, the head of the hospital's community outreach office, said the idea of paying commissions was considered but never adopted.
"We never did that," she said. "I said someday maybe we might do that if we ever got into the red."
'The Big Push'
As Riverside's director of social services from 1999 to 2000, Ron La Fleur supervised the intake division, the first step in the admissions process. He said in a recent interview that he frequently clashed with Riverside administrators, who he said pressed him to admit children he believed did not need in-patient psychiatric services.
"The big push was not to turn down any admissions and find a way to get these children admitted," said La Fleur, a licensed social worker.
When children were not admitted, La Fleur said, he and other employees were reprimanded by Riverside administrators. "They would come into my office and say, 'Why didn't you admit these kids?' " he recalled. "Many times, these kids didn't need an acute level of care."
One night in the fall of 1999 , La Fleur said, a woman brought her daughter to Riverside for a psychiatric evaluation. The girl had been running away and her mother didn't know what to do. La Fleur said the girl confided during an interview at the hospital that she was being sexually abused by her sister's boyfriend and was too terrified to tell anyone. La Fleur said hospital administrators wanted to admit the girl anyway, saying she needed psychiatric care because she was suffering from oppositional defiant disorder.
"We had a real argument about it," La Fleur said. "The point was to stop the sexual assault. That's not mental illness. She was running away for a reason. This was twisted for pathology, and for Riverside to gain financially."
La Fleur said he lost the argument, and the girl stayed at Riverside for about a week before she was discharged. La Fleur said he told supervisors that he believed there was a pattern of improper admissions for financial gain. When he realized little would change, he said, he resigned in 2000.
Groves disputed La Fleur's contention that the girl did not need treatment.
"That child was endangering her own life by running away," Groves said. "We don't let people come here without getting help."
Parents of children and former workers assigned to supervise cases said that once children were admitted, it was often difficult to persuade hospital administrators to discharge them.
In April 2000, Charita Pope, a psychiatrist who worked at Riverside for nearly four years, took over the care of a 16-year-old foster girl, according to three sources familiar with the case. For nearly six months, the girl had been confined to the hospital's acute-care wing, where children stay at a cost of $700 per day. Pope changed the girl's medication, and within two months the girl improved dramatically, the sources said. Pope recommended that the girl be discharged.
Riverside hospital officials: Arti Subramanian, chief financial officer, left; Barbara Groves, community outreach; Rebecca Fishman, president; Sushma Jani, medical director. (File Photo)
But Jani, the medical director, allegedly recommended that Pope send the girl to the hospital's residential treatment wing, which charges $250 per day, according to the sources. Pope disagreed and discharged the girl.
In an internal Riverside memorandum obtained by The Post, Pope accused Jani of retaliating against her for her action.
"In my judgement the decision of the team was the most clinically appropriate outcome for the patient," Pope wrote in the June 1, 2000, memo. "Therefore, I could not in honest concur with your recommendation."
Jani declined to discuss the memo.
"It is customary for me to review and question their care and recommendations, and we can agree or disagree, and that's all I can say," she said.
'It Was Horrible'
As a court-appointed mentor, Deborah Smith worked with the city's foster children. In 2001, she was assigned to the case of a 16-year-old girl who had been in and out of group homes before a judge sent her to Riverside. The girl had emotional and behavioral problems, but Smith said she believed they did not require treatment in a psychiatric hospital. Smith said she tried to find a foster family for the girl, who had been at Riverside for more than a year.
"They weren't doing anything to get her out of there," Smith said. "In fact, I got the feeling that they were trying to keep her."
Smith said hospital administrators kept changing the girl's discharge dates and coming up with reasons to keep her. Finally, Smith said she and the girl's social worker found a foster family willing to take the girl and persuaded hospital psychiatrists to let her go late last year. She said the girl is doing well in her new home.
"They were intentionally keeping her," Smith said. "I know they were getting quite a bit of money for each child, and I'm sure that's why they kept changing the dates she could be released."
Groves said the hospital could not discuss the cases of specific children but denied keeping children for monetary reasons. "If someone was kept here, it wasn't for the money," she said.
Michele Brackenridge said she had a similar experience. In May 2002, her 13-year-old daughter was referred to Riverside by a private physician for a psychiatric evaluation because of severe emotional problems. Brackenridge said she frequently called the hospital to find out when her daughter could come home.
"They would say, 'Well, maybe tomorrow, maybe the next day,' " she said. "I got the sense they were keeping her to make more money."
Brackenridge said doctors were not performing the tests and examinations the hospital had promised and they were not returning her phone calls. Riverside discharged Brackenridge's daughter after a 10-day stay. She said her daughter looked like a "zombie" when she returned home.
"It was horrible," Brackenridge said. "All they did was give her medication."
Groves reiterated that she could not talk about individual patients and denied that the hospital overmedicated patients. "Our policy is not to overmedicate," she said.
The District is in its own battle with Riverside over the length of time the hospital keeps children. A firm hired by the city to audit the hospital's Medicaid bills concluded that Riverside kept 148 children for 6,884 days of "unnecessary medical stays" from 1997 to 2001, resulting in $4,520,700 in overcharges, according to the Department of Health.
One foster girl stayed 88 days longer than necessary, costing taxpayers an additional $61,600, according to a series of audits by the city's contractor, the Delmarva Foundation for Medical Care Inc. One foster boy stayed 108 days longer than necessary, costing an extra $75,600. Another foster boy stayed 158 days longer then necessary, costing an additional $110,600.
Attorneys for Riverside are contesting Delmarva's findings, arguing that many of the children were sent to the hospital under court orders that did not specify release dates. Because the District has failed to define what constitutes an "unnecessary medical stay," Delmarva did not have a standard to judge Riverside, the attorneys argued.
A city hearing officer agreed with the hospital's argument that the District did not have such a definition, but James A. Buford, director of the Department of Health, on Wednesday "disapproved" the hearing officer's decision, saying that the officer had no jurisdiction over the matter. Yesterday, a spokeswoman for Buford said the city will seek to recoup the $4.5 million from Riverside.
"Our view is he lost that right to make that decision," said Joel Hamme, a Riverside attorney. "He had more than 90 days to issue a final decision. He's gone way beyond that. We've never received his decision. He doesn't have the right anymore to overturn that."
Several former Riverside employees said city officials share some of the blame for the extended stays. The former employees said the hospital has become a parking place. City social workers often left children at Riverside and forgot them, the employees said.
"We had a reputation for accepting everyone and anyone," said Christal Campbell, who supervised a girls' unit at Riverside before resigning in 2001. "We were a dumping ground."
Monitors for Child and Family Services recently put down in writing a reason why Riverside is so important to the District. But they added a caveat.
"Not only is it conveniently located in the upper northwest quadrant of the District, keeping within the 100-mile radius, but it allows for families to participate in face-to-face family therapy sessions, and weekly visits with their children," the monitors wrote in a June 4, 2002, report. "However, recognizing these conveniences should not allow us to compromise the quality of care of our children."
Database editor Sarah Cohen, Metro researcher Bobbye Pratt and staff writer Justin Blum contributed to this report.