State licensing officials are reviewing multiple "significant concerns" about patient supervision at Sierra Tucson, a treatment center where a prominent California doctor was found dead this summer.
A team from the Arizona Department of Health Services recently found more than 30 licensing violations at the for-profit medical facility, including a failure to comply with its own procedures on patient care, state records show.A state enforcement team will review the violations Tuesday and decide whether to issue a fine or take other action, said Bill McCarroll, a team leader in the state's office of behavioral health licensing. McCarroll confirmed the state held a meeting with Sierra Tucson officials Oct. 6 to review "significant concerns and inadequate client supervision" at the treatment center. "We want to know that the way they provide general supervision is improved," McCarroll said...
Litwack was discovered dead on the Sierra Vista grounds Aug. 30 - two weeks after he initially went missing. His body was discovered by staff members walking the grounds with a patient and a horse, according to the Pinal County Sheriff's Department. The body was near the stable about a quarter-mile from the main building at 39580 S. Lago del Oro Parkway. Autopsy results are not yet available.
After Sierra Tucson reported Litwack's Aug. 16 disappearance to the state, the team visited the facility and subsequently wrote a 65-page report detailing violations, including failing to have any policies and procedures for certain clients to enter and leave the center, and also failing to prove that all its staff members had received sufficient on-site training. The treatment center has two levels of care: Fifteen beds are for top-risk Level One acute psychiatric care, and 124 beds are for lower-risk "Level Two" care. The state violations all pertained to Sierra Tucson's Level Two beds, the report says.
The report identifies a "Client No. 1" who did not show up for a group session the morning of Aug. 16. The report says the facility's director of risk management told an investigator that the last time Client No. 1 was seen by a staff member was at 1 p.m. that day, and that an agency "Amber alert" was issued at 3:15 p.m. "At this time the psych techs began driving around the perimeter of the
facility searching for Client No. 1. However, the deceased body of Client No. 1 was not discovered until Aug. 30, 2011," the report says. The report also says Client No. 1 had a diagnosis of major depression and was initially admitted to the high-risk Level One psychiatric area of the facility. But the records say that on Aug. 13 he was transferred to the lower-risk Level Two area...
Previously fined Sierra Tucson has been in trouble with the state at least once before for improper supervision of its patients. In 2009, it paid $3,500 to the Arizona Department of Health Services related to two incidents involving patients leaving the grounds - one when a patient with a history of psychosis left the facility without permission, and a second when a patient with suicidal thoughts, who had also threatened to rape another patient, was discharged and left in his private car without any documentation that he was safe to leave by himself. The violations were found during an investigation following a complaint.