Fundamental Flaws: Addiction Treatment Providers In Pa. Face Little Scrutiny Despite Harm To Clients

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This investigation is a joint mission of KHN, a nationwide newsroom that produces in-depth journalism about well being points, and Spotlight PA, an impartial, collaborative newsroom devoted to producing investigative journalism for all of Pennsylvania.

When Ian Kalinowski was at work, his mother normally texted him. So when he noticed her quantity present up as an incoming name round lunchtime one Tuesday, he figured it needed to be essential.

Now, greater than seven years later, he remembers her screams, the shock, and the questions she requested time and again.

“Why are they saying this to me? Why are they mendacity to me?” Ian recalled his mother asking. “They’re telling me Adam’s lifeless. Why would they do that to me?”

Adam was Ian’s older brother. Rising up, it appeared they spent each second collectively. Soccer, hockey, and tag crammed lengthy days outdoors their Pittsburgh residence. When Ian moved away for school, he and Adam turned to on-line poker to remain in contact. Adam served as greatest man at Ian’s marriage ceremony, and Ian admired his brother’s creative streak. Adam may flip any piece of paper into an origami swan. His mother’s residence continues to be stuffed with swans.

Adam’s battle with opioid and alcohol habit was painful for Ian to look at. The issues started, it appeared to Ian, after Adam dropped out of faculty and used medication to take care of his melancholy. Adam sought remedy, and he relied on methadone for a few years, however his issues continued. When he was 32, he usually drank dozens of beers every day. On Feb. 3, 2014, he entered a remedy heart run by Habit Specialists Inc., in keeping with a lawsuit later filed by his household in opposition to the power. The middle, in a Fayette County strip mall, was about an hour’s drive south of Pittsburgh.

Lower than 24 hours after Adam made it to the power, he was lifeless, in keeping with professional reviews from medical doctors within the household’s wrongful loss of life lawsuit. Ian couldn’t perceive what went incorrect, and neither may his mother, nonetheless in denial on the opposite finish of the telephone name.

What his household didn’t know was that Habit Specialists Inc., usually often known as ASI, had a historical past of violating state guidelines. In a later federal investigation into the power’s billing and drug distribution practices, a grand jury concluded {that a} litany of issues occurred on the enterprise many months earlier than and after Adam’s arrival.

Within the wrongful loss of life go well with, a lawyer for the Kalinowski household alleged Adam wasn’t evaluated by a doctor when he arrived at ASI, didn’t obtain the treatment or remedy he wanted, grew to become more and more uneasy and anxious all through the evening, and killed himself. An Allegheny County choose in December 2019 stated the enterprise, two of its homeowners — Rosalind and Sean Sugarmann — and an ASI doctor have been negligent in caring for Adam. The choose ordered them to pay over $1.6 million in damages, though Ian doubts they ever will.

ASI ultimately shut down, two years after Adam died.

In latest interviews with Highlight PA/KHN, the Sugarmanns denied accountability for Adam’s loss of life and maintained that ASI was facility. Rosalind stated it helped lots of people in a rural space with a excessive drug-overdose price.

Habit remedy amenities in Pennsylvania, like ASI, are licensed and controlled by the state to make sure they observe sure guidelines and preserve susceptible folks battling habit protected. Oversight used to fall to the Division of Well being. However in 2012, the state created the Division of Drug and Alcohol Applications, a $125 million company set as much as give substance use the eye lawmakers felt it deserved.

On the time of Adam’s loss of life in 2014, the division had taken few disciplinary actions in opposition to ASI. It had issued and required the corporate to submit plans to right them. However the Sugarmanns instructed Highlight PA/KHN that, on the time, they didn’t concern the state would shut them down.

 

Maybe for good cause.

A Highlight PA/KHN investigation discovered that the division has allowed suppliers to proceed working regardless of repeated violations of state rules and hurt to purchasers. Greater than 80 interviews and a evaluation of 1000’s of pages of state authorities and court docket information revealed that the division lacks assets and regulatory energy, makes use of an inherently flawed oversight system that does little to make sure high-quality or efficient care, and infrequently takes robust disciplinary motion in opposition to amenities when so many Pennsylvanians want providers.

The division has no normal standards for when it ought to pressure amenities to serve fewer sufferers and, as of early April, had revoked only one remedy supplier’s license in practically a decade. It doesn’t, as a daily follow, examine amenities to see if any stand out for an uncommon variety of violations or probably the most shopper deaths. And since state inspections focus closely on information, they are often tricked with fraudulent paperwork, former workers within the remedy discipline stated.

This leaves Pennsylvanians — that suffer one of many highest drug overdose death rates in the nation — at the hours of darkness about which remedy amenities have troubling monitor information.

Some advocates level out that overregulating or closing amenities may go away folks affected by habit with out choices for care. However within the present system, state and judicial information present, some sufferers have obtained insufficient remedy and even died; sure amenities have fraudulently billed insurance coverage firms; and homeowners rake in federal and state tax {dollars}, in addition to non-public cash from victims of the opioid disaster.

“Many of those rehab amenities aren’t correctly run or supervised, and plenty of are in it for the cash,” stated Peter Friday, an legal professional who represented Adam’s household of their lawsuit. “These locations have been unbridled.”

 

 

Who polices the suppliers?

Despite the fact that the Division of Drug and Alcohol Applications offers the licenses that enable habit remedy amenities to function, Jennifer Smith, secretary of the division, stated it has restricted accountability for them. Regulation enforcement companies are sometimes higher positioned to take motion in opposition to troubled suppliers, she stated, and insurance coverage firms that pay for providers additionally supply oversight.

“It’s not our job to essentially police the suppliers,” Smith stated in an interview. “Our operate is to essentially attempt to allow them to satisfy the [state’s] necessities, and by doing so, enabling them to supply high quality providers.”

But, because the regulating physique of those remedy amenities, the division collects a few of the most crucial info essential to correctly police them, together with reviews of shopper deaths and bodily and sexual assaults.

Smith stated most suppliers are attempting to do good work. She stated annual inspections guarantee amenities meet security requirements, like having sufficient employees members and a constructing that’s as much as code. However inspections aren’t meant to judge high quality of care, she stated.

The Highlight PA/KHN investigation discovered the division makes little of what it is aware of about troubling amenities accessible to the general public. Its web site exhibits if a facility at present has a provisional license — a designation indicating the supplier failed to satisfy a number of state necessities and shall be inspected extra incessantly till it resolves these issues — however not whether or not it ever obtained such a sanction previously, for what points, nor how they have been resolved.

The division doesn’t submit the reviews it collects about deaths and assaults, which signify a few of the most regarding occasions at remedy amenities.

When Highlight PA/KHN filed a public information request for these reviews, the division shared solely incidents that it determined didn’t warrant investigation. It stated it couldn’t present the whole variety of such occasions at particular amenities because it doesn’t have combination knowledge previous to September 2019, when it launched a new electronic reporting system. Even the accessible knowledge from that new system offers an incomplete image, as lower than 1 / 4 of remedy amenities had enrolled within the voluntary system as of March 2021.

Smith stated folks ought to decide amenities the identical approach they do main care medical doctors, primarily based on publicly accessible info, private suggestions, and discussions with insurers.

One of many fundamental public assets the division presents is a web site with reports from its facility inspections. Inspectors write these reviews after a web site go to, itemizing any violations of state rules they discovered. However these reviews present a restricted window into the every day actuality for purchasers, as there’s no indication of which violations are extra extreme than others, and plenty of rules give attention to constructing circumstances and completion of information. One regulation, for instance, mandates the temperature at which refrigerated meals should be maintained.

In response to every violation inspectors discover, the power submits a plan to handle it. If the power fails to supply a plan or observe by on it, the division has two main choices: pressure the power to scale back the variety of purchasers it serves or challenge a provisional license. If the division desires to completely revoke a facility’s license, it should undergo an administrative court docket course of to get approval.

In practically a decade earlier than December 2020, the state issued provisional licenses to fewer than 80 amenities — lower than 10% of suppliers — and compelled solely three to scale back their capability, in keeping with knowledge from the division. In ASI’s case, regulators stated a number of occasions that the corporate didn’t doc that it supplied required counseling and different providers. A division spokesperson stated it didn’t pressure ASI to function beneath provisional licenses earlier than 2015 as a result of the enterprise submitted plans of correction the division discovered acceptable. Even when a facility has many violations, the division considers how cooperative it’s in working to repair them, Smith stated.

After a latest reorganization, the division shaped a top quality enchancment unit with three workers, Smith stated. The unit may fit straight with remedy amenities however is supposed to handle broader prevention efforts and different addiction-related packages as properly. The division can be working with a nationwide firm to supply a web based platform the place purchasers can go away evaluations of amenities, beginning in spring 2022.

However many workers and purchasers within the remedy discipline are skeptical of any long-term enchancment. For years, they’ve seen troubled amenities make fixes, solely to have the identical deficiencies come up in later inspections.

The division’s personal information present the cycle can persist for years.

 

 

Years of citations, little motion

At SOAR Corp methadone clinic in Northeast Philadelphia, inspectors from the state Division of Well being first issued citations for unqualified workers in 2009, earlier than the Division of Drug and Alcohol Applications was created and took over inspections in 2012. Inspectors on the time additionally discovered one counselor who was liable for 40 purchasers — above the state-mandated most of 35.

SOAR Corp responded by saying it had demoted an unqualified counselor, had employed one other counselor to decrease caseloads, and would guarantee future hires met the state’s necessities.

However state information present that inside a yr of these 2009 citations, the power was cited three extra occasions for comparable points: hiring an unqualified project director, overloading counselor caseloads, and lacking enough medical personnel. 12 months after yr, state inspectors discovered the identical issues. But the state permitted SOAR to open extra places in Lansdowne, Levittown, and Warminster in 2010, 2016, and 2018, respectively.

In interviews with Highlight PA/KHN, a dozen former workers and practically a dozen present and former purchasers throughout a number of SOAR websites complained about poor hiring practices and persistent understaffing as simply two signs of their a lot bigger issues. They believed the corporate relentlessly pursued income by getting as many purchasers within the door as potential, with little look after the standard of remedy.

The Philadelphia location has obtained three provisional licenses from the state, in 2012, 2019, and 2020, placing it among the many 10 most frequent recipients of this sanction over practically the previous decade.

The previous counselors felt that expectations to maximise “billable hours” led to their burnout. And so they noticed excessive turnover amongst staffers. The previous and present purchasers stated they often went weeks with out remedy or have been switched from one overwhelmed counselor to a different each few months.

 

Nicole Tihansky was a shopper at SOAR’s Levittown location for a couple of yr till final fall. She stated she waited greater than a month earlier than getting her first counseling session, after which was assigned about 5 counselors, one after the opposite.

“It makes you simply wish to get out and in of the session shortly, as a result of you recognize you’ll get one other counselor in a month,” she stated.

Understaffing is an issue throughout the remedy trade, in keeping with workers within the discipline. However former SOAR workers who’ve labored for a number of firms stated SOAR stood out of their experiences for its excessive employees turnover and insufficient remedy.

“It’s not about remedy or addressing the wants of purchasers,” stated Esther Kirshenbaum, a counselor who labored on the Philadelphia location from 2017 to 2019. “The perspective is to only get purchasers in right here and ensure we receives a commission.”

In a press release, SOAR CEO Richard Mangano stated the corporate “makes each effort to adjust to native, State, and Federal rules.”

Highlight PA/KHN shared with SOAR an in depth checklist of greater than a dozen allegations from their reporting, together with violations of state rules and placing income over affected person care. Mangano didn’t handle them particularly.

“Soar Corp categorically denies any allegation or suggestion of wrongdoing. … Soar Corp has and can proceed to work with DDAP to enhance the essential providers it offers,” Mangano wrote, referring to the Division of Drug and Alcohol Applications.

In its responses to state citations lately, SOAR defined that purchasers didn’t present as much as scheduled counseling periods, and that providers like drug assessments and doctor evaluations had been supplied however merely not documented correctly.

The Division of Drug and Alcohol Applications has by no means compelled SOAR to lower its capability, nor have state officers initiated the executive court docket course of to completely revoke its license.

Former purchasers and workers stated state licensing inspections have been introduced forward of time, inflicting a rush by SOAR workers within the days earlier than a web site go to to finish remedy plans, counseling notes, and different required paperwork.

Nicholas Cucchiaro was a SOAR counselor from 2017 to 2018. He shared with Highlight PA/KHN what he reported to the Division of Drug and Alcohol Applications and the Pennsylvania Workplace of Legal professional Normal after he was fired. He instructed the companies {that a} senior administrator at SOAR instructed him to make up counseling notes for purchasers who had gone weeks with out an assigned therapist.

“These are notes from remedy periods that by no means occurred,” he stated, including he knew it was incorrect however feared dropping his job if he didn’t comply.

A few dozen different former workers and purchasers described to Highlight PA/KHN their very own experiences of comparable practices, starting from thrusting months’ value of kinds upon purchasers within the days earlier than an inspection to backdating their paperwork.

The Division of Drug and Alcohol Applications and the legal professional normal’s workplace each agreed to look into the allegations, Cucchiaro stated, however he didn’t hear of any penalties for SOAR.

The legal professional normal’s workplace instructed Highlight PA/KHN that it reviewed “a small quantity” of complaints concerning SOAR and referred the matter to the Division of Drug and Alcohol Applications.

Smith, the division head, stated that as a normal matter it’s tough to stop amenities from falsifying paperwork, as a result of state rules require advance discover of licensing inspections. But when the division receives a grievance, it could actually conduct unannounced inspections, she stated, and different amenities have been cited for fraudulent paperwork.

Unannounced web site visits have been made in response to the complaints at SOAR, in keeping with a division spokesperson, and citations have been issued for violations that didn’t embrace fraudulent paperwork. SOAR’s Philadelphia location obtained provisional licenses in 2019 and 2020, however as of mid-April all the corporate’s websites have been working on full licenses after remedying the cited points.

A rising trade

One vital limitation on the division’s oversight is its lack of ability to impose monetary penalties on remedy amenities.

In distinction, the state’s environmental safety and well being departments can superb polluters and nursing houses for violations.

A 2017 report from the state auditor normal’s workplace urged lawmakers to allow the department to cost licensing charges and assess monetary penalties, pointing to different states that accomplish that. Smith instructed Highlight PA/KHN that fining amenities would assist weed out repeat violators.

A invoice launched within the Pennsylvania legislature to permit the division to generate licensing charges went nowhere two years in the past. A similar measure was lately referred to the state Senate Well being and Human Companies Committee.

“I hope that it’s thought of shortly as guaranteeing drug remedy amenities are given applicable oversight is of utmost significance,” the invoice’s sponsor, state Sen. Judy Schwank (D., Berks), stated in a press release.

In the meantime, with tens of millions of {dollars} on the road, the remedy trade is rising in Pennsylvania. Over the past 4 years, the state has seen a internet achieve of about 40 amenities, the division stated, bringing the whole to greater than 800 remedy suppliers. State price range paperwork counsel the trade’s shopper capability has grown by about 5,000 over an analogous interval.

The Division of Drug and Alcohol Applications employed 82 folks, together with two dozen who conduct facility inspections, as of April. That’s about half the number of dog wardens employed by the state to examine kennels.

Smith stated there may be “satisfactory employees to carry out our present licensing duties.”

In December 2018 — the identical yr the division stated it obtained complaints from former SOAR workers and purchasers — it permitted the corporate to open a location in Warminster. Inspection surveys on the facility since have discovered it violated state guidelines by providing a certain medication with out state approval and failing to provide the required hours of remedy to some sufferers.

A former SOAR supervisor who continues to be working within the remedy trade and requested to not be named doubts the state will ever take stronger motion in opposition to the corporate.

“The state is aware of the demand for remedy and the demand for medication-assisted remedy,” the previous supervisor stated. “Should you took SOAR’s license in Northeast Philadelphia and didn’t give them a provisional, you may be displacing 500 purchasers.”

The necessity for remedy

The urgency of the opioid disaster places regulators in a troublesome place: In the event that they shut down a facility, the place will all of the sufferers get remedy?

James McKay, a professor on the College of Pennsylvania’s medical college who researches the efficacy of habit remedies, stated amenities which can be committing insurance coverage fraud or actively harming sufferers ought to be penalized. However the query turns into extra difficult when judging how properly a facility is serving its purchasers.

In Philadelphia, the place there are various remedy packages, it’d make sense to shut one which has ineffective interventions, untrained counselors, and many purchasers dropping out, McKay stated.

“However if you happen to’re out in the midst of the state and there’s just one remedy program in any cheap distance, so long as they’re not treating you badly, you’re no less than going to get some help and meet others in restoration,” he stated. “A lot of this relies on what the opposite alternate options are.”

In Western Pennsylvania, an inpatient detox and rehab facility known as Clear Day Therapy of Westmoreland has obtained a number of provisional licenses because it opened in 2018. State inspectors have famous no less than six incidents that concerned medication on the premises and have cited the power no less than twice for understaffing, writing that the shortage of adequate employees fails to make sure “efficient and safe operation.”

Regardless of these issues, the power is the one one within the county that gives detox providers whereas permitting sufferers to remain on any of three drugs for opioid use dysfunction. Many sufferers within the space want that service, stated Colleen Hughes, govt director of the Westmoreland Drug and Alcohol Fee Inc. (The fee is one in all greater than 40 companies throughout the state that the Division of Drug and Alcohol Applications contracts with to coordinate substance use providers domestically.)

The fee decided in 2017 {that a} lack of residential rehabs within the county was one issue delaying folks’s remedy. Clear Day responded to a request for proposals to satisfy that want from firms that handle Medicaid-paid behavioral well being for the state in that area. Clear Day has been awarded practically $750,000 in state Medicaid funds left over from earlier years to assist with start-up prices, in keeping with Southwest Behavioral Well being Administration, Inc., one of many firms that put out the request.

Stephen Devlin, govt director of Clear Day, stated in a press release that Southwest Behavioral Well being Administration carefully monitored these funds, which helped the power present “a lot wanted” habit remedy providers.

“State auditors have been diligent in guaranteeing that Clear Day addressed all deficiencies which were recognized throughout audits,” Devlin wrote, “and, additional, that Clear Day offers robust and efficient remedy to the people in our care.”

Hughes stated her workplace has addressed the problems of understaffing and medicines on the premises with Clear Day by conferences and coaching periods.

Smith, head of the Division of Drug and Alcohol Applications, stated: “None of us wish to see suppliers closing. We wish them to achieve success. We wish them to have the ability to ship the providers for his or her profit and for ours.”

 

Ready for penalties

In Fayette County, ASI got here beneath hearth from state and federal authorities in 2015.

The FBI raided the facility that October. The next January, a federal grand jury indicted one of many homeowners, Rosalind Sugarmann, and an ASI physician on a number of counts of illegally distributing a medicine to deal with opioid habit.

Practically three months later, a counselor employed by ASI overdosed whereas staying on the facility, an legal professional for the state later stated in an administrative court docket submitting in opposition to ASI. Finally, a chapter case compelled the enterprise to shut.

In late 2016, Sugarmann pleaded responsible to unlawful drug distribution and well being care fraud. However that hasn’t saved her and her household out of the restoration enterprise. Lower than a yr after she was launched from jail, Sugarmann — who has talked publicly about her personal substance use a long time in the past — introduced she was opening a restoration residence.

“I’m not going to cease working with addicts ever. That’s my calling in life,” Sugarmann stated in an interview with Highlight PA/KHN. “Someone helped me, and I assist any person else.”

However two households stated Sugarmann failed their family members.

There’s Adam Kalinowski, who died at ASI in 2014, and there’s 37-year-old James Pschirer, who died of an overdose in a restoration residence Sugarmann’s household operates. These houses supply peer help and infrequently have curfews and guidelines designed to assist folks avoid medication after they’ve been discharged from inpatient remedy.

In Kalinowski’s case, Sugarmann stated ASI reported his loss of life to everybody it was required to. There’s no indication from division information that the state cited ASI in connection together with his suicide.

(The Division of Drug and Alcohol Applications wouldn’t touch upon Kalinowski’s case particularly however stated it labored with the FBI to analyze issues at ASI.)

Neither Sugarmann nor her husband, Sean, mounted a protection in opposition to the Kalinowski household’s lawsuit in court docket. In a latest interview with Highlight PA/KHN, Sean Sugarmann positioned the blame for Kalinowski’s loss of life elsewhere, saying that the power was staffed appropriately and that, given his eventual suicide, Kalinowski by no means ought to have been despatched to ASI.

Kalinowski’s household additionally sued UPMC Mercy, the Pittsburgh hospital the place he was handled earlier than going to ASI, and affiliated entities, however resolved the claims in opposition to them by a non-public settlement, in keeping with a household legal professional. UPMC denied accountability for Kalinowski’s loss of life. In a pretrial court docket submitting, an professional witness for UPMC directed blame at ASI, saying Kalinowski was properly sufficient to be safely discharged to a residential remedy facility. That he wasn’t evaluated by a physician, nurse, or skilled counselor when he arrived at ASI was a priority, the professional wrote, and “maybe this tragedy may have been prevented” if ASI had supplied the next degree of care.

Extra lately, Rosalind Sugarmann has confronted criticism for her involvement with restoration houses.

 

In February 2019, whereas nonetheless beneath federal supervision, Sugarmann introduced on a weblog that she was “again in fee!!” and would open a males’s restoration residence known as The Second Act outdoors Pittsburgh.

A 2017 regulation gave the Division of Drug and Alcohol Applications new energy to control restoration houses along with remedy amenities. The state missed a June 2020 deadline to implement the voluntary licensing course of however plans to roll out this system this yr.

James Pschirer turned to The Second Act for a spot to remain within the fall of 2019. His mom, Andrea Zack, helped him with lease, writing out a $250 examine to Sugarmann, in keeping with a photocopy of the examine the household supplied.

Then, on Nov. 1, 2019, James died inside the house from a fentanyl and cocaine overdose, a photograph of the loss of life certificates supplied by his household confirmed.

Andrea and James’ sister, Amanda Pschirer, went to The Second Act to gather his garments and private gadgets. Andrea saved the cash in his pockets, understanding he had touched them.

It wasn’t till after James’ loss of life that his household came upon about Sugarmann’s legal conviction, they stated.

Amanda is aware of her brother selected to make use of medication, however she thinks he may nonetheless be alive if he had stayed in one other residence with higher oversight. And she or he’s offended that nothing stopped Sugarmann from being concerned with one.

“I’m fearful that another person will die beneath her care,” Amanda stated.

In interviews, Rosalind and Sean Sugarmann downplayed their involvement with The Second Act. “My youngsters are concerned within the restoration houses,” Rosalind instructed Highlight PA/KHN. “I’m not an proprietor there.” The enterprise is registered of their youngsters’s names, and Rosalind stated she’s lived in Los Angeles since early 2020.

Nonetheless, Sean Sugarmann acknowledged serving to his grownup youngsters handle the enterprise, and stated in March he was dwelling within the males’s residence at the moment. One among his daughters referred questions on The Second Act to Sean. Rosalind promotes the enterprise on social media accounts, encouraging folks to maneuver in. She instructed Highlight PA/KHN, “I’m not gonna deny that I’m a guide.”

Sean stated an overdose loss of life “may have occurred anyplace, and I believe it occurs in all places.”

Final fall, Amanda Pschirer reached out to state officers with issues about restoration houses. However she stated she didn’t obtain a response for 4 months. The division stated a pc glitch with a web based type, found in January, induced the delay in responding to her submission and about 260 others.

Ian Kalinowski, whose brother died at ASI seven years in the past, has adopted Rosalind’s posts on-line and noticed that she’s nonetheless concerned within the restoration enterprise. He’s outraged.

He and his household are nonetheless grieving Adam’s loss. Ian needs his younger youngsters had gotten to satisfy their uncle. He doubts the ASI defendants will ever present the $1.6 million-plus that the choose stated they owe.

Ian acknowledges that ASI’s leaders confronted some penalties for issues on the enterprise.

“However there have nonetheless been no repercussions for what occurred to my brother,” he stated of the Sugarmanns.

He’s not optimistic there ever shall be.

 

KHN (Kaiser Well being Information) is a nationwide newsroom that produces in-depth journalism about well being points. Along with Coverage Evaluation and Polling, KHN is among the three main working packages at KFF (Kaiser Household Basis). KFF is an endowed nonprofit group offering info on well being points to the nation.

  Spotlight PA is powered by The Philadelphia Inquirer in partnership with PennLive/The Patriot-Information, TribLIVE/Pittsburgh Tribune-Evaluation, and WITF Public Media. The impartial, nonpartisan newsroom is funded by foundations and readers like you who’re dedicated to accountability journalism that will get outcomes: spotlightpa.org/donate.

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