Government Scout

Documenting Death in Texas

Maybe it’s October or the fast-approaching Halloween holiday. Or maybe forensic science touches the science geek in me. But I’ve always been interested in how death is documented, both in data and by people sources. 

After I posted information yesterday about how reporters can document a CPS investigation, John Tedesco, (my terrific reporting colleague at the San Antonio Express-News), emailed me about another unsung doc reporters can obtain from urban medical examiner’s offices.

John writes:  

     There’s one more resource that might be helpful, although I haven’t specifically done this in a child abuse case. In addition to the autopsy report, in Bexar County, Travis County, and probably other large counties with medical examiners, you can also request a copy of the investigator’s report. It offers a chronology of what the M.E.’s office did that’s usually packed with details you can’t find in the autopsy report.

With this document John was confirm the Air Force was investigating a nurse suspected of over-medicating an elderly patient.

Medical examiners’ offices are located in large urban areas. Some handle autopsies from other smaller surrounding counties.  

I always shake my head at how there are still (yes, Dallas, Bexar, Travis, Galveston counties, I’m talking about you) medical examiner offices that require a paper or mailed request to get an autopsy. Shameful, really.  

Nevertheless, here are some of the frequently used ME links for reporters:

• San Antonio - Bexar County. $25 for an uncertified copy of an autopsy. Outrageous price. 
• Dallas - Dallas County. Requires paper request to be MAILED to them. And they charge $5 for an uncertified copy of an autopsy. 214.920.5921, for questions.  
• Houston - Harris County. You can check the status of the case here. And they charge 10 cents a page for a copy. 
• Fort Worth - Tarrant County
• Austin - Travis County. Paper request. 
• Galveston - Galveston County Requests can be faxed. Sigh. $25 for an autopsy report (outrageous). They are mailed to you.  

In smaller Texas counties, the justice of the peace (JP) is the person called to declare someone is dead. 

I love talking to JPs. Finding them is easy if you have the Texas State Directory bookmarked on your computer.

While I’m no Luddite, I like the paper version of the TSD (about $25).

My 2009 TSD has Post-it note tabs on the counties I frequently search for and if you have the book version, it’s easier to tote in the car.

JPs have often turned out to be some of the best sources for me. Some will give you a description of the location where the deceased is found, what the weather was that day, give you excellent detail about the scene, (was the deceased found inside or outside a house, office, car, etc), how the body was found and was positioned and what was next to the deceased. They are often the first eyes after a police agency has responded.

This is not salacious info. A lot of times, what JPs have observed provides great information to readers about the deceased, about how the investigative process works and when investigators knew what. 

Any information I get from a JP I always vet through other witnesses at the scene. By doing that I get a sense of whether there was confusion or organization at the scene. 

As John said, the medical examiner’s investigation report is very useful.

In 2005, I used one from the Galveston County ME’s office to find out where the deceased were located at the Texas City BP plant following the explosion that killed 15 people. That helped us get a picture of what had happened. And it helped us later determine whether people were working too close to the source of the explosion. 

Cemeteries and funeral homes are also a good source, although not a public one, when writing about the deceased.

I try when possible to visit where the person I’m writing about is buried. For larger cemeteries, ask for a plot map. When I wrote about a very high-profile child abuse death, I drove to Brenham, where the girl was buried. I found out that on the eve of the murder trial of the two suspects, (the girl’s mother and the mother’s boyfriend), the child did not have a headstone. I was shocked. And so were a lot of readers. 

When writing about children’s deaths, I always ask the funeral home who handled the service if they have a copy of the program printed for the service. Many times, you’ll find some touching details in them you will not find in police reports. Many funeral homes provide an online program, through Legacy.com and other services. But it’s worth asking for a copy of a paper program. 

Got a question about public records in Texas? Always glad to help. Email terri.langford@chron.com

How to Document a CPS Investigation

Texas CPS investigations are confidential.

But reporters can - and should - write about them.

Today’s story about the tragic missteps behind the Tamryn Klapheke child abuse case in Abilene relies on several public records and a tiny bit of data. 

First, anytime there’s a suspicious death, it pays to start with the preliminary autopsy report. 

But two lesser known documents played a crucial role in this story and not every reporter knows to ask for them. 

The first is what Texas Child Protective Services refers to as a “personnel action.”

While you can always ask for the personnel file of any public service worker (they are subject to the Texas Public Information Act), it can take weeks to get a copy of one. 

Instead, reporters should ask if there are any “personnel actions” in a worker’s file and get copies of those. 

The second document is a relatively new one and it’s called a 2059. You can find the 2059 in the Tamryn Klapheke case, here. 

A 2059 is only available after a child abuse investigation has been completed. It gives the public a summary of the findings. The law creating this new document was authored by state Sen. Carlos Uresti, D-San Antonio.  

Also, as CPS caseload is becoming more of a problem again for investigators, I now ask CPS for a list of all caseloads numbers for particular time periods for each worker in a county. You’ll find the “average” caseload number is interesting but fairly useless. 

Here’s Taylor County caseload numbers, by investigator. What was interesting to me is that a handful of caseworkers were shouldering most of the investigations in Abilene. You won’t get that if you ask for the “average” caseload for a region, or a city. 

Here’s another thing reporters should always try to see. I say see, because they are rarely released. 

If the dead or injured child had siblings who were removed from their home, then I ask to see what is known as a CPS Affidavit, a document filed in district court in child abuse cases.

I request to view these documents in court, under Section 58.005 (7) of the Texas Family Code as a party “having a legitimate interest in the proceeding or in the work of the court.” Most of the time, I am allowed to view them. 

Although CPS caseworkers are the authors of this document, by law, they do not not release them. You have to ask a judge to see them and it is up to the judge whether to grant you permission. In this case, I knew the Abilene judge in the case, had sealed the affidavit.  

Questions? Email me at terri.langford@chron.com.  

Riverside General Hospital, PHPs and Medicare

For those readers and reporters who have asked, here’s a better organized explanation of partial hospitalization programs or PHPs, as well as a list of documents and websites I use and a history of the investigation at Riverside General Hospital. 

It’s been a difficult year for Riverside General Hospital, the tiny, 98-bed hospital in Houston’s Third Ward that was once the Houston Negro Hospital but shed its segregation-era name in 1961.

On Feb. 8, Mohammad Khan, the assistant administrator of Riverside’s partial hospitalization program, housed in satellite mental health clinics, was arrested.

Khan,a naturalized US citizen, born in India and trained as a doctor in the Dominican Republic (but never licensed in Texas) was arrested for filing $116 million in phony Medicare claims for mental health care at Riverside.

Weeks later, he pleaded guilty and is scheduled to be sentenced next year.

Four months later, on June 8, the Centers for Medicare and Medicaid Services, also known as CMS, decided to suspend Medicare payments to Riverside, because the agency believed there were “credible allegations of fraud perpetuated to the benefit of Riverside in the past.”

Congresswoman Sheila Jackson Lee, a staunch supporter of the hospital, located in her district, asked the agency on June 18 to reconsider its decision because the suspension presented a “potential harm to patients.”

CMS declined to do so.

By July, the suspension of Medicare payments had taken its toll on Riverside. On July 12, the FBI returned, taking more files and employees complained of bounced paychecks. A week later, Riverside’s offsite mental health clinics suspended services, effectively closing.

In August, CMS, the agency that once said it believed there were “credible allegations of fraud” at Riverside, reversed itself and turned 70 percent of the payments back on to Riverside. CMS confirmed that action to me, explaining that they did so because: 

“CMS made this adjustment to ensure vulnerable Medicare beneficiaries in Houston continue to have access to the critical health services they need, while at the same time safeguarding Medicare Trust Fund dollars. We are carefully scrutinizing Riverside’s claims to make sure they meet all Medicare requirements for payment.”

Then, on Thursday, Earnest Gibson III, Riverside’s CEO since 1982, and his son, Earnest Gibson IV, who operated one of the clinics, were indicted, accused of organizing a $158 million Medicare scheme involving five suspected co-conspirators who were paid kickbacks to recruit patients for Riverside’s clinics.

Here is the indictment that was unsealed last Thursday (Oct. 4, 2012): 

Riverside Indictment

According to the indictment, Medicare-eligible patients were supposedly lured to Riverside’s programs with cigarettes, food and coupons redeemable in Riverside’s “Country Store.” The items in the store, according to a price sheet obtained by the Chronicle, seen below, cost anywhere from 2 “Country Store dollars” to 30 and included a range of items, from candy bars to disposable cameras.

Riverside CS

The case is set for trial Dec. 10. Although it is likely that it will be reset as often happens in court cases. 

But who are these patients? Where do they come from and why are they eligible for Medicare if they’re under 65 years of age? 

First, Medicare is not just a program for those over 65. It can also be tapped to assist the mentally ill. For more information about history of how this usage has spiked, the National Alliance on Mental Illness (NAMI) has a nice explainer here.

Basically, in an attempt to reduce the cost of expensive psychiatric hospitalization for the mentally ill, the government appeared to expand the use, beginning in 1990, of “partial hospitalization programs” (PHPs) and “community mental health centers” (CMHCs). 

A PHP is a service offered by a hospital or an affiliated clinic. A CMHC is a stand-alone operation that offers PHP services. In the last year,  the federal government has tightened up rules about CMHCs and so many are affiliating now with a hospital. 

Texas regulates hospitals. But it does not regulate these programs or the clinics. 

The indictment against Riverside involves their satellite clinics offering PHP services. 

The first PHP prosecution to get any notice, was in October 2010, when owners of American Therapeutic Corporation in Miami were charged in a $205 million scheme to funnel patients from personal care homes and assisted living facilities to their clinics.

I could be wrong, but I believe the ATC case is still the single largest - by dollar amount  - Medicare fraud prosecution. 

 Partialhospitalization.com is actually a good reference tool that I discovered when I was learning how these clinics operated for the ambulance stories I wrote a year ago. 

Another PHP under investigation is Spectrum Care, as well as ambulance providers who brought patients there. FBI agents seized records at Westbury Community Hospital, but have yet to make any arrest. 

Please send any questions about PHPs, or anything else, as well as story ideas to: terri.langford@chron.com. 

CPS Backlog - What does it mean?

A lot of people ask me if it’s depressing writing about abused children, particularly the ones who die.

I tell them no. It’s more depressing to think about an abused child, particularly one who dies, will not have their last story told.

Still, I’m hesitant about writing anything more about Texas Child Protective Services. I’ve written just about every angle of this state’s child abuse investigation system and the parent agency, the Texas Department of Family and Protective Services. 

From the basic tragic breaking news story to what is essentially a reporting autopsy examining what exactly happened. From new programs to new problems. 

I’ve looked at how trends point to problems and stresses within the system. 

But one thing I had not written about until August, is exactly how children’s cases get lost in the system and can result in death. How do children who are well-known to CPS, die anyway?  

So a few months ago, I wrote about Julia Martinez, a toddler whose case was scheduled to graduate from the investigation stage to what is known as Family-Based Safety Services or FBSS. Her case never made it there and her overwhelmed caseworker forgot about it, and she died. 

But that opened the door to something every state social service reporter has written about, a hundred times, particularly when it comes up in the Texas Legislature: caseload backlog.

And I’m about as guilty as anyone when it comes to buying the state’s “average” caseload numbers. What any average always shields though, is the range: the low number and particularly, the highs.

In Houston, caseworkers are seeing a lot of the highs.  

So Julia’s death led me to ask questions about what really were the numbers behind that “average” caseload in Houston.

What I found was, despite the reforms, the efforts, the attempts to add more workers, raise pay, etc., the backlogged caseload in Houston was unmanageable. And it had been exacerbated by an effort last spring to borrow caseworkers from strapped offices in Houston to Austin and West Texas to help out overwhelmed workers there.

So what does caseload backlog really mean? When workers can’t close out their cases, that is ,interview all the parties, come to a conclusion in the case and make a referral about what to do next, the inaction puts children at risk a second time and in some cases, like Julia, they die. 

Although the state is zeroing in on this problem now, particularly in Houston, this issue will likely be coming up again, when the Texas Legislature meets next January. 

Children’s Medicaid Therapy in Texas

Today’s story takes a look at Medicaid spending on three types of therapy for poor children: physical, occupational and speech. 

I’m not a clinician and realize these descriptions may be too simplistic.

Occupational therapy refers to therapy for fine motor movements, cognitive skills. If a child were handed a recipe, for example, or asked what they do first when buttoning their coat, tying their shoe, can the child tell you what the steps are to complete the task? If a child has trouble with movement of hands, cannot dress herself, or understand how to plan activities, they could be diagnosed as needing occupational therapy.

Physical therapy focuses on a child’s range of motion, muscle control, addresses problems with walking, for example. Patients includes those who have been injured or have a birth defect. 

Speech therapy helps children who have language difficulties caused by autism, or a congenital problem, injury, hearing loss, or other developmental delays. 

I had asked the Texas Health and Human Services Commission, Medicaid’s overseer, for payments based on therapy when I heard about the temporary restraining order obtained by Rio Grande Valley clinics last week over the way Medicaid-funded van service is used there to shuttle child patients to clinics. 

Medicaid is more than a health insurer. It often helps the state’s neediest residents - poor children - by removing barriers to care caused by a lack of transportation. In Texas, HHSC pays a transportation contractor to operate vans, or issue vouchers for public transit to families who qualify. 

Once I received the therapy payment data, I combined it with the van battle in south Texas after seeing that Hidalgo County leads all other areas, including other large border counties like El Paso and Laredo, when it comes to Medicaid payments for therapy services. 

Highest Medicaid Therapy Costs by County.

Several readers asked today why I didn’t complete the analysis by looking at per-child-cost.

We can’t really do that. The payment totals-by-county number is captured based on where the clinic provider lives - not the child. Medicaid-eligible children could live in one county and receive treatment in another, making such an analysis impossible to do at this time. The column showing the number of children under 19, who receive Medicaid, by county, is more of a benchmark and a guide for readers that can’t be used in a calculation. 

HPSAs and PHPs

Here’s a breakdown on two stories I had this week about two different Medicare-funded programs. 

The first story, was about the HPSA, or Health Professional Shortage Area. These areas are supposedly reviewed and blessed by federal Health Resources and Services Administration (HRSA), a division of the U.S. Department of Health and Human Services, based on states’ health data. 

The shortage areas (HPSAs) play a key role in luring primary care docs and psychiatrists to rural or poorer areas in the United States that have little regular access to health care. 

Makes sense. If the government wants to improve something, say health care, it’s a good ideal to pinpoint population areas where health care is non-existent.

There’s a handful of incentives to get primary care doctors to consider working in a  HPSAs.

Physicians can qualify for medical school loan forgiveness if they relocate to a HPSA. If they’re a foreign doctor, the J-1 visa requirement that they return home, is waived.

And then there’s this: for each Medicare claim they file while working in the HPSA, they get a 10 percent bonus. Per claim, filed. Not per claim, reimbursed. 

While interviewing a fraud investigator for another story I am working on, he  mentioned the bonus program to me. Never heard of it. Tell me more. He referred me to a few documents. 

The first, available online is here. I’ve also Scribd-ed it to my docs page on this tumblr. It’s a 2005 HHS OIG report on rural clinics and explains, there on pages 2-3, in the introduction, how HPSAs work. 

“HRSA designates shortage areas for the purpose of directing placement of providers or program funding for nearly 30 departmental programs focused on alleviating access problems in such locations.” 

The HPSA (shortage area) program began in 1978. But in this document and another, the HHS OIG noted problems with HRSA not updating the areas. 

No updates means those areas that have overcome their medical access issues siphon off benefits they may no longer qualify for. 

In the Rural Clinic audit, that problem surfaces by page 8: 

“Sixty-one percent (169) of these RHCs are located in areas that HRSA has not designated as shortage areas.  The remaining 39 percent (110) are located in urbanized areas defined by Census.”

Then there’s this Sept. 26, 2011 HHS OIG memo - (not available online and there really is no good reason for that)  to the HHS deputy secretary. It essentially points out that, this lack of updating what areas are medically needy, is costing money via Medicare bonuses.

The HHS OIG memo quickly points out that because there’s no timely updating of HPSAs, areas doctors in areas once considered medically needy are working in areas that have become so urbanized they no longer qualify for the HPSA and subsequently the bonus program. By the HHS OIG’s own accounting an estimated $64 million has been overpaid to docs in Hidalgo County, which no longer qualifies. Two months later, Hidalgo and 310 other areas were stripped of their HPSA status.

However, Hidalgo is still a HPSA based on a lack of mental health services.

Now onto today’s story which is all about another costly Medicare acronym: PHPs

Partial Hospitalization Programs, or PHPs were designed to be an intensive alternative to a psychiatric hospital stay. Here’s how TrailBlazer Health Services, the billing contractor for the Centers for Medicare and Medicaid Services, explains it:

“Psychiatric partial hospitalization is a distinct and organized intensive psychiatric outpatient treatment of less than 24 hours of daily care, designed to provide patients having profound or disabling mental health conditions with an individualized, coordinated, intensive, comprehensive and multidisciplinary treatment program not provided in a regular outpatient setting.”

In Texas, neither a PHP nor its stand-alone cousin, the for-profit Community Mental Health Center, are facilities regulated by the Texas Department of State Health Services (DSHS).

However, Medicare requires that PHPs be offered either by a hospital or at a clinic affiliated with a hospital. The Texas health department requires only that hospitals with PHPs, tell them they have a PHP.

Hospitals are not required to tell Texas DSHS where their PHP (the physical address) is housed or located.

And that’s become a problem in Houston, where many clinics have sprung up offering PHPs, but not clearly stating which hospital they are affiliated with.

In the past year, I’ve seen more PHPs that were housed in the equally fuzzy - and unlicensed - Medicare entity known as a CMHC, now call themselves a hospital-based PHP and shed the CMHC from their name. That appeared to be the case of the Hornwood clinic run now by Westbury Community Hospital.

In 2010, when I first started work on what became the Chronicle’s series on private ambulances, the Hornwood clinic was owned by Continuum Health Services and it was classified as a CMHC. By 2011, it had a new name (Westbury) but the owners were the same. And it was no longer called a CMHC. 

Stay tuned. We’ll see more on this issue, this year.  

Questions? Please email terri.langford@chron.com