By LEE WILLIAMS and ESTEBAN PARRA
The News Journal
10/30/2005
A former drug and alcohol counselor who worked for Correctional Medical Services at Gander Hill prison claims company officials ordered her to falsify documents so state inspectors would not pull the company's license to run a prison treatment program.
Denise Rodriguez, who worked for Correctional Medical Services at the prison's drug and alcohol treatment program from 1999 to 2002, said she would have been fired if she refused orders to fabricate entries contained in inmate files.
"I was told to do progress notes on people who were not my clients," said Rodriguez, now a substance abuse counselor at the Latin American Community Center in Wilmington. "I told them I didn't want to falsify the charts."
The order, she said, came from a supervisor at CMS, one of the largest correctional health care companies in the country.
"I received a chart that wasn't touched for four months," Rodriguez said. "I was told to 'catch the chart up' using previous statements from the client."
If an inmate had admitted a cocaine addiction, for example, Rodriguez said she was told to write that the client was making progress overcoming the problem -- without ever talking to the inmate about the addiction. Other documents were back-dated or altered with correction fluid, she claims.
Rodriguez, a 37-year-old mother of three, said she decided to talk about her work at Gander Hill after reading a series of News Journal stories detailing problems with the delivery of health care to inmates in Delaware.
The St. Louis-based CMS no longer runs the drug and alcohol program, called Key, but last July received a $25.9 million no-bid contract to provide health care for the more than 6,600 inmates in Delaware's prison system.
Lucian Gambino, Rodriguez's former supervisor, said when he worked in the prison he was aware counselors were updating records at a furious pace and that other supervisors ordered the changes. Gambino worked in the Key program from December 2001 to December 2002.
"I knew our people were trying to update records that were very delinquent, that had not gotten through the previous state licensure, or for some reason were just not completed at all," Gambino said. "The pressure on all of us was really great. We had lots of catch-up work to do. We had work that had not been done by folks from previous years."
Gambino, however, said he never personally ordered anyone to do anything wrong. He, too, was acting under orders from the same CMS official named by Rodriguez, he said. When contacted by The News Journal, that official declined to comment.
Key began at Wilmington's Gander Hill prison in 1988, and is now offered at three Delaware Department of Correction facilities. Inmates can request to enter Key, or participation in the substance abuse program can be ordered by a judge during sentencing.
According to the DOC Web site, Key is a therapeutic community for men and women -- "a total treatment environment that is discipline-based, intense and isolated from the rest of the prison population."
Today, approximately 420 inmates participate per year.
CMS administered the Key program from 1987 through June 2002 under a contract, worth as much as $1.6 million annually, that required a valid state license. If Delaware regulators uncovered falsified information, the contract would have been at risk.
"If there was known forgery, the license could have been in jeopardy," said Jay Lynch, spokesman for the Delaware Department of Health and Social Services.
CMS chose not to bid on the current contract, which is now administered by Civigenics, a private corrections firm based in Marlborough, Maine, with operations in 17 states.
Since his company has run the program, Civigenics Executive Vice President for Operations George Vose said he has never heard of an allegation about fabricated information. "That would certainly not be standard operating practice in any Civigenics operation," Vose said. "If I was made aware of that, I would take immediate disciplinary action."
Faults noted
Over several years, regulators from the Delaware Divisions of Substance Abuse and Mental Health issued reports that indicate the Key program was rife with sloppy or incomplete paperwork.
The News Journal obtained minutes from a management meeting of the Key program held Jan. 13, 2003, showing that inmate files and state inspections were major concerns.
The document says two supervisors spent more than two hours "doing disciplinary business regarding files" and that one of them felt "licensing will be here either this week or next week."
When Rodriguez was hired in 1999, for $12 per hour, she had no formal education beyond the 12th grade, and no training in counseling or substance abuse. She admits she was an odd choice for a drug and alcohol counselor.
"I know the only reason I got the job was because I spoke Spanish," she said. "They had no Hispanic staff. They had inmates translating for inmates, which raised serious privacy concerns."
Gambino considered Rodriguez one of his best counselors.
"She was a very conscientious young lady," said Gambino, who left CMS after a job injury. He later sued CMS for disability compensation and received a settlement, and is currently disabled.
"She was really sincere about wanting to do the best job she could. She had a natural talent for communication, and could communicate with clients in a way that was really most effective."
CMS spokesman Ken Fields said he has never heard of allegations that former staffers were ordered to falsify reports.
"To the contrary, any request to falsify documents would be a clear violation of established policies and procedures," Fields wrote in an e-mail to The News Journal. "In fact, during orientation programs, CMS emphasizes to staff the importance of keeping accurate and up-to-date records."
The orientation program, though, was criticized by state regulators from the divisions of Substance Abuse and Mental Health during the years CMS ran the Key program and more recently when Civigenics was in charge.
During an inspection conducted in November 2000, regulators examined 13 personnel files of counselors assigned to the Key program.
"Five did not contain documentation of orientation," the report states.
In March 2004, four of the 11 personnel files examined did not document orientation.
During an inspection conducted over two days in March of this year, regulators examined 11 personnel files. They found seven contained no documentation of orientation.
Department of Correction spokeswoman Beth Welch said the DOC has never received complaints of record tampering.
"If the ex-employee cares to make a complaint, the department will fully investigate," Welch said in an e-mail answering questions from The News Journal.
Welch declined to respond directly to the allegations raised by Rodriguez or to problems found by state inspectors. Instead, her response to the newspaper contained a paragraph taken from the DOC's Web site which touts the effectiveness of the Key program.
'The family'
For Rodriguez, a typical day in the Key program began at 8 a.m. inside Gander Hill, when she walked into the dorms to wake up some of the 230 inmates in the program at that time.
To increase the program's effectiveness, inmates assigned to Key are segregated from the general prison population, and live in dorms rather than cells.
Female counselors, sometimes alone, would wake the inmates, screaming "Feet on floor! ASAP! ASAP!" Rodriguez recalled.
The Key program is based on structure, regimentation and discipline. It has been compared to a military boot camp. Intensive one-on-one, group and peer counseling is central to the treatment philosophy. Inmates can be punished for rule infractions, or kicked out of the program and sent back to the general prison population.
Correction Commissioner Stan Taylor has lectured about the program in Washington, D.C., and in Latin America. Inmates in the program are referred to as "the family."
Rodriguez said she was at the mercy of "the family," especially when she was the only counselor on the floor.
There were two guards in the dorms, but they were separated from the inmates in glass observation bubbles.
"There were a lot of blind spots where the guards couldn't see," she said. "If I was attacked in the shower area, they would have been unable to help."
Rodriguez said she never received personal security or self-defense training.
Despite the rigors of the treatment program, inmates with AIDS and other medical problems were forced to participate.
"The AIDS patients had it the worst," Rodriguez said. "There were times they couldn't get out of bed, and the guards wouldn't let them go to medical. The guards made the decisions about who was sick. They decided who went to medical."
To provide some level of care, Rodriguez taught the inmates cures taught to her by her Puerto Rican grandmother.
"We used ice and tea," she said. "Ice would stop bleeding. We used it on one client who was bleeding from his rectum. We used tea bags to stop toothaches."
Rodriguez and the other counselors were supposed to have a caseload of 30 clients, but because of high turnover -- most stayed only one or two years -- caseloads sometimes grew larger, she said.
Often, Rodriguez said, she would be told to falsify progress notes in files that hadn't been touched for months.
"I told them I didn't want to do it," she said, even though she faced disciplinary action if she didn't. "They told me I was gonna get a ding if the charts were not caught up."
Licensure
Conditions in the Key program became frantic before inspections by state regulators.
"We were told to change the files when the inspectors were coming, or if we even thought they were coming," Rodriguez said.
Frann Anderson is the unit director of Licensing and Medicaid Certification, part of the Delaware Department of Health and Social Services' Division of Substance Abuse and Mental Health.
Anderson, and others from her unit, inspected the Key program annually. They never suspected files were being altered.
"We never saw anything that led us to believe that occurred," Anderson said. "We go in and read the records. Our intent is to see if things are proven according to standards. We read what's there and we may give feedback -- basically is the paperwork there or not. Anything missing would have been cited."
The inspection reports, prepared by Anderson and her staff, show that progress notes were a frequent problem.
Despite the irregularities -- found when CMS had the contract and when Civigenics took over in 2002 -- state inspectors always granted the Key program a license.
Reports over a period of five years, obtained by The News Journal, demonstrate a recurrence of either conflicting or missing information in patient charts. A sampling of the problems includes:
•On June 15, 1999: "The progress notes often did not include the actual date services were provided or the length of time the group was held. Notes frequently included non-clinical jargon, i.e. 'Client appears plugged into the process.' and anticipated treatment that is expected, i.e. 'I will continue to work with this client on his problems.'"
•On Nov. 28, 2000: "In one chart the notes were conflicting. The assessment section of the progress note summarized self disclosure statements made by the client, but the plan section of the same note stated that the client was not sharing and unwilling to do so. In one chart there were four weeks of progress notes that were blank except for dates that had been written at the top."
•On Jan. 25, 2001: "In ten charts the progress notes did not contain facts, impressions and anticipated treatment and at times reflected a lack of clinical knowledge and experience. For example, one note indicated, 'Being that I just started the caseload with this client I will need more time because I believe that he is mental.'"
•On Nov. 12, 2001: "In thirty charts (of the 33 examined) the progress notes did not reflect the progress being made in meeting current treatment plan goals."
•On Feb. 22, 2002: "In one chart the entire note for one week of services, over 13.5 hours of treatment, stated, 'Client attended participated in staff seminars and attended and participated in Encounter group to confront and address negative behavior and attitudes.'"
•On March 9, 2004: "In 21 charts (of 22 examined) progress notes were missing."
Despite the inspectors' findings, Fields said CMS stresses good record keeping.
"As we have previously stated, during orientation programs and ongoing compliance training, CMS emphasizes to staff the importance of keeping accurate and up-to-date records," he told the newspaper in a written response. "During the normal review process by the state's Division of Health and Social Services, if it is determined that any additional information should have been included in records, an agreed-upon corrective action plan is put into place. After that time, the Division conducts additional reviews."
Harris Taylor, senior social work supervisor for the Division of Substance Abuse and Mental Health, said his regulators don't consider the effectiveness of a treatment program when conducting an inspection.
"The effectiveness of a program is not something we really look at," Harris Taylor said. "The effectiveness is not all that well documented in the field."
Up to vendor
Who does determine whether a taxpayer-funded program is working?
"That's done internally," Harris Taylor said. "We review their quality-assurance plans. It's up to the programs to ensure quality assurance."
Dr. Carol A. Tavani, a board-certified neuropsychiatrist and executive director of Christiana Psychiatric Services, questions whether the aggressive approach advocated by Key actually works.
"When I first encountered the technique in prisons, I was taken aback by it," Tavani said. "Some people are helped by the structure and limit setting. However, many women have been abused in their youth, and have post-traumatic stress and poor self-esteem. When they're subjected to the yelling and threats of restraints, it can be counter-therapeutic. They can't comply and they're punished. It's like punishing someone with a broken leg for not being able to run."
More troublesome for Tavani is poor training.
"So much substance abuse is co-morbid with psychiatric problems and mental illness," she said. "If somebody doesn't pick them up and they miss the dual diagnosis, they've missed the boat. If someone is not comprehensively trained, there's a danger they'll miss the secondary diagnosis and only treat the substance abuse. They'll detoxify the individual without addressing the reasons why."
Code blue
Rodriguez misses working at the prison. She regrets that she was forced out.
When she complained that a guard was sexually harassing her, the guard force went "code blue."
"They all pulled together," she said. "Once you make a complaint against a guard, they'll get you."
Within weeks of the verbal complaint, Rodriguez said she lost her clearance to enter the prison. Her ID card was confiscated. Even though she was still employed by CMS, she was not able to work at the prison.
"I got along well with the inmates. I was highly respected. I loved my job," she said. "After I complained, one guy told me they were going to get me fired."
Contact investigative reporter Lee Williams at 324-2362 or lwilliams@delawareonline.com. Contact Esteban Parra at 324-2299 or eparra@delawareonline.com.
