State psychiatric hospital employees raise alarm over rampant turnover and ‘crisis’ of leadership 

In late March, a group of nurses at Montana State Hospital received a rare dose of good news. Local labor advocates had filed a petition to create a union for advanced practice registered nurses, among the most highly trained medical providers at the state’s sole adult psychiatric facility, in Warm Springs.

But the nurses spent little time celebrating. In emails obtained by Montana Free Press, members of the group instead tried to explain the scope and seriousness of their workplace concerns to union representatives of the Montana Nurses Association. 

“Our wages are incidental to something far more concerning underway at a level of state hospital administration that doesn’t include us,” one staff member wrote in an email to MNA organizers. Montana Free Press has agreed to withhold the employee’s name out of respect for their fear of professional retaliation. 

“We have a crisis of patient safety and care, of shifting practices and processes, and a lack of regard of the medical team providing care at MSH that I never would have imagined could occur,” the advanced practice nurse continued. “It’s like being stuck in a recurring bad dream.”

The emails, hospital records and interviews with more than a dozen current and former hospital staff portray a troubled public facility suffering from turnover of key medical personnel. Those who remain describe bad management, concern for patient safety, fear of reprisal and burnout as the administration of Gov. Greg Gianforte pushes for reform at the facility two years after it lost certification from the federal Centers for Medicare and Medicaid Services. 

The Warm Springs campus, just north of Butte, contains more than 260 beds for patients with serious mental illnesses, including those facing criminal charges and others with dementia or traumatic brain injuries. The state health department, which oversees the facility, had funding for approximately 475 full-time hospital employees in early 2024.

The hospital’s loss of certification, sparked by patient deaths, falls and safety concerns, removed a key layer of federal oversight and created an urgent problem for the governor’s office. Without certification, the hospital is ineligible for millions of dollars in federal reimbursements for patient care. The facility’s damaged reputation also makes it more difficult to recruit staff and has hung over the Gianforte administration like a stubborn storm. 

With a goal of applying for recertification by January 2025, Gianforte and his appointed director of the state health department, Charlie Brereton, have pursued a facility overhaul: The state has hired consultants, established a governing board for the hospital, invested in facility repairs and announced hiring incentives.

But some of the administration’s strategies are raising alarm and frustration throughout the hospital’s workforce. Providers, many of whom asked for their names to be withheld out of fear of retaliation from the administration, say the latest changes in leadership and medical protocols make it difficult for them to do their jobs well, and don’t make the psychiatric facility safer for patients or better positioned to regain federal certification.

“I can tell you this is going to hell fast,” one of the hospital’s current practitioners said in a recent interview, requesting anonymity to avoid potential retaliation. “If they don’t start treating the medical staff in a humane way, there will be no one who can take care of patients.”

In response to a list of questions about employee concerns, Brereton said Wednesday the state hospital is undergoing a “​​significant cultural, clinical, and operational transformation” after “decades of neglect from previous administrations and inadequate oversight from Helena.” The director also appeared to accuse some medical staff of providing improper care but did not make specific allegations about current or former employees.

“Our dedicated providers and staff who put patients first must continue to be recognized for their good work,” the statement said. “Consistent with our legal obligations, those that fail to care for patients, improperly prescribe medication, perform procedures without consent, misuse seclusion and restraint, and outright refuse to acknowledge the merit of federal certification and oversight will continue to face appropriate consequences for their harmful and dangerous actions.”

COMINGS AND GOINGS

In mid-December, hospital employees learned that Dr. Thomas Gray, the hospital’s longtime forensic psychiatrist and chief medical officer, had been escorted out of the campus’ main building and placed on paid administrative leave. The reason for his removal was not announced, and staff members told MTFP his abrupt exit spawned a degree of paranoia. Some described Gray, who had decades of experience at the hospital, as a cornerstone of the institution. If he could be removed so quickly for unknown reasons, who else could be?

Gray could not be reached for comment. Four current hospital staff members told MTFP that the administration had prohibited Gray from speaking with them — and they with him — since his departure, despite his continuing to live in staff housing on campus for several months. 

In its Wednesday statement, the state health department said Gray “is no longer an employee of DPHHS” but declined to comment further, citing confidential personnel records.

Also in December, the state hired a chief medical officer, Dr. Micah Hoffman, through Traditions Behavioral Health, a California-based staffing company. State Medicaid director Mike Randol announced Hoffman’s new role at a January public meeting, but Randol did not mention that Hoffman would work remotely from Wyoming or that chief medical officer for Montana’s sprawling hospital campus would be just one of the jobs in Hoffman’s portfolio — circumstances that Hoffman has since communicated to hospital staff.

The state health department did not deny that Hoffman lives in Wyoming, but, in a statement, said that he is “onsite every other week, and when not onsite is directly engaged with the day-to-day operations at MSH remotely.”

Other leadership changes were announced early in 2024. The hospital’s interim administrator and CEO, David Culberson, left abruptly in January after less than a year on the job and roughly a year before the end of his contract. Culberson did not respond to MTFP’s request for comment about his time at the hospital; the state health department reiterated Culberson’s status as a temporary worker and said “DPHHS reserved the right to terminate his contract at any time.” 

Instead of hiring a permanent CEO or bringing on another contractor, a higher-up employee in the state health department in Helena, Jennifer Savage, assumed Culberson’s responsibilities in January. In an email to hospital staff shared with MTFP, Savage said she was taking over the job while retaining her administrative role overseeing other state-run health facilities. 

“At this time, David will be moving onto the next chapter, and we wish him all the best. Effective immediately, I will serve as the acting MSH CEO until further notice, in addition to my duties as Healthcare Facilities Division, Chief Administrative Officer,” Savage wrote. “Thank you in advance for your patience as we make this transition and energetically move forward with re-gaining CMS certification of MSH.”

Savage, who began working for the state health department in 2023, spent roughly three years as a business director for public health facilities in North Carolina but does not have a background in clinical care. Multiple current and former hospital employees recalled having one of their first interactions with Savage in January when she and Randol stressed their unequivocal approach to CMS certification in a town-hall-style meeting with workers from across the campus.

The message relayed was: “This is the way it’s going to be. If you don’t like it, there’s the door,” recalled Liz Robinson, a former MSH staffing supervisor who spoke to MTFP about the meeting. Robinson resigned from her position in early April after more than two years at the hospital because of what she described as stress, negative interactions with management and unrealistic work expectations. “All they care about is getting that certification back. They don’t care how they do it or who they have to lose.”

Robinson said the turnover in leadership positions had been a recurring concern since the hospital lost certification in 2022. But, she said, the transition between the unassuming and soft-spoken Culberson and Savage has been particularly challenging.

“It’s her way or no way,” Robinson said. “I understand you have to have someone with a backbone who will stand up and do stuff, but you have to treat your staff with some sort of respect or dignity.” When Savage took the helm, she added, “People really started dropping off.”

“All they care about is getting that certification back. They don’t care how they do it or who they have to lose.”

Liz Robinson, former staffing supervisor, Montana state hospital

Hospital staff learned of other departures in March and April. An advanced practice registered nurse left at the end of March. The facilities manager announced his resignation in a staff-wide email. A certified behavioral health peer support worker did the same, saying she’d made her decision “with a heavy heart.” Another nurse practitioner put in her notice in mid-April.

Robinson’s manager in the staffing division, Pam Kehl, also left in early March. In a recent interview, Kehl said she had worked for the state hospital for roughly 20 years but that the last six months were “probably the worst I have ever seen it.”

After working through the COVID-19 pandemic, the loss of CMS certification and other challenges, Kehl said she was ultimately driven to an early retirement by changes in staffing policies, confusing communication and stressful dictates from Savage and other administrators. 

“Every time we turned around they were piling more stuff on the staffing office. And if I questioned why they were giving it to us, [the response was] ‘Well, if you can’t do it, we’ll get somebody else to,’” Kehl recalled. “It just kind of went downhill from there.”

Some leading medical staff were also departing, or considering it. Dr. Michelle McCall, a psychiatrist, submitted her notice of resignation in mid-March. Current employees say Dr. Daniel Bemporad, a forensic psychiatrist, put in his notice at the beginning of April but later decided to stay at the facility, though for unknown reasons.  

Reached by MTFP, both Bemporad and McCall declined to comment on their employment status or workplace conditions.  

‘A DECISION THAT WAS MADE IN HELENA’

Remaining medical staff have raised alarms about policy changes directed by Savage, Hoffman and state-hired consultants. 

In an effort partly intended to rein in costs, employees say the administration has discouraged providers from placing patients under the direct supervision of one dedicated staff member — a protocol known as 1:1 staffing — and told them to justify any direct supervision to administrators in writing if it continues longer than a day. Providers say the new standard puts pressure on staff to bypass one of the best strategies for monitoring patients who are at high risk of injuring themselves or harming other patients or staff, particularly in the Spratt Unit, which houses many older residents with dementia. 

Concerns about that and other changes boiled over during virtual video meetings between medical staff in April, recordings of which were shared with MTFP. 

At a mid-month meeting, some employees described the new 1:1 rules as an “ethical dilemma” — a choice between upholding high standards for patient care or risking being penalized by the administration.

“The current administration’s strategy seems to be to intimidate the prescribers of 1:1s to not do it by punishing them, by spending a fairly good proportion of their day writing useless emails,” Dr. Christian Bachman, a traveling doctor, said to his colleagues during the April 16 conference. 

Referring specifically to the Spratt Unit, Bachman continued:

“If we didn’t have any 1:1’s, there’s going to be people dying over there. I think everybody knows that,” he said to his colleagues. “And so is that going to fall on the shoulders of the medical practitioners there that didn’t have time to do this or was afraid of losing their job? That’s not right.”

In a statement provided to MTFP, the state health department said the revision to the 1:1 policy to include regular reviews is meant to ensure that providers “are more actively engaged in treatment and incident prevention” and was not implemented solely to decrease costs.

On a video call in early April attended by Hoffman, staff pushed back on another recent change: restricting medical staff’s access to security footage after incidents involving patients. 

One of the hospital’s psychiatrists, Dr. Howard Sampley, told the interim chief medical officer that the new limitations interfere with patient care and medical decision-making. If a patient falls, hits their head or is assaulted by another patient, having quick access to a video review is vital, he said. “And that could be cleared up in a matter of minutes, sometimes, from looking at one of those films.”

Other providers said the new protocol delays their ability to review footage for as long as five hours. They predicted that, if patients needed to be quickly transferred to a nearby hospital emergency department to be assessed, the policy would cost the administration more money.

Hoffman said the rule, communicated in a March 29 staff email from Savage that was reviewed by MTFP, is the result of concern for the privacy of patients and staff. Any flexibility, he said, was unlikely.

“I can certainly bring it back up to them, but this was definitely a decision that was made in Helena and not unique specifically to the clinical practice in the hospital,” Hoffman said. “I’ll be totally honest, I don’t know how much movement there is on the subject.”

Another provider, Dr. Virginia Hill, next asked to discuss the increase in documentation requirements about patients’ progress but began with a specific request.

“I’d like to be assured that my comments won’t result in some type of retaliation or referral to H.R.,” Hill said. 

Hoffman didn’t reply, but Hill continued. The new expectations for daily and weekly patient notes had “quadrupled my workload,” she said, adding that she would not be able to comply without additional resources. “I know that there may not be any movement on it, but I thought I need to alert somebody that it would be impossible to implement right now,” Hill said. 

Again, Hoffman referenced directions from Helena and the state-hired consultants from the New York-based firm Alvarez and Marsal.

“I will be honest, this was the recommendation and direction of the consultants. Director Brereton’s office has been clear that CMS certification is the only path forward. The consultants have been clear that the increased note frequency is the only capacity to meet that path forward. So that’s the reality of the situation,” Hoffman said. 

Other providers echoed Hill’s concerns. Bachman suggested that the increased workload could be tackled with the right tools, like transcription and dictation services common in other health care facilities. But, he said, Savage had said during a prior staff meeting that adding those resources was unlikely.  

“Director Brereton’s office has been clear that CMS certification is the only path forward. The consultants have been clear that the increased note frequency is the only capacity to meet that path forward. So that’s the reality of the situation.”

Dr. Micah Hoffman, Interim chief medical officer, Montana State Hospital

“I might be the right guy to make this comment because I’m a short-timer, and I don’t have as much of a dog in the fight,” Bachman said. “I think everybody wants to do an excellent job. However, if we recall a couple of weeks ago at one of these meetings, not only was this recommendation made to do four times as much paperwork, but also we wouldn’t get transcription services and we basically better learn to type,” he said.

He continued, addressing Savage directly. 

“I want to say, if Jennifer Savage is listening, you might think twice about speaking that way to people who are trying very, very hard to do a good job. And to say, ‘Yeah, we want you to do all this, but no transcriptions,’” Bachman said. “What message does that send to the medical staff?”

The issue with documentation had not abated by the next time medical staff convened for a meeting on April 16. At that gathering, Bemporad, the forensic psychiatrist, described the increase in documentation as “excessive” and not realistic for the criminally charged people he works with.

“For those clients, seeing them four times a week could be detrimental because they’re overtly psychotic, they’re paranoid, they’re hostile,” Bemporad said. “Seeing them four times a week like that, it actually annoys them. It ruins your relationship with them.” 

Bemporad and other staff discussed that the new standard was above and beyond what is required by federal regulators, but the policy handed down by the state didn’t seem to have any room for negotiation, regardless of providers’ opinions.

“Like I said, this is the directive that we’re given,” Bemporad said to the other staff members. “So we’re doing it.”

‘BURNED THEIR BRIDGES’

The state health department said Wednesday it is currently searching for a permanent CEO but stood by reforms and changes implemented in recent months under Savage’s leadership.

“Difficult decisions are being made and newfound accountability isn’t always popular — but Jennifer and DPHHS leadership will always put patient safety and quality of care above all else,” Brereton said in the written statement. “I have full confidence in Jennifer as a change agent at MSH.”

“I want to say, if Jennifer Savage is listening, you might think twice about speaking that way to people who are trying very, very hard to do a good job.”

Dr. Christian Bachman

At recent public meetings and appearances before lawmakers, Brereton has repeatedly committed to achieving recertification of the state hospital and stressed that the administration’s decisions are meant to stabilize the hospital. But the state health department has also acknowledged that staff retention and recruitment is a stubborn challenge.

In a January presentation about the state health department’s Healthcare Facilities Division, Medicaid director Randol said the state hospital continues to rely on contracted temporary staff more than any other state facility, such as veteran homes and the Montana Mental Health Nursing Care Center in Lewistown. Compensation for traveling doctors and nurses at the hospital accounted for 81% of all spending on contractors at state facilities in 2023, he said, although that figure was projected to drop to 77% in the next fiscal year. 

Statewide, Randol said, the anticipated use of contracted staff, who are typically paid at higher rates than permanent staff, will overrun the allocated budget by more than $13 million for the current fiscal year. He said the state has conducted pay studies, implemented raises and hiring and retention bonuses, and expanded recruiting efforts. But Randol declined to promise how much the state aimed to, or could, limit the use of temporary contractors.

“We will continue those strategies as we move forward to determine how we can reduce the utilization of contract staff. But I’ll be candid with you: We’re never going to get down to zero at some of these facilities. It’s just not going to happen,” Randol said. “But we will do everything we can to have the appropriate level of contract staff versus state [full-time employees].”

The state has implemented other measures to reduce costs while still using traveling providers. Kehl, the former staffing manager, said the administration had recently put firm restrictions on overtime for state employees and contractors, opting to hire more travelers rather than paying out for excess hours. But bringing in that many new people isn’t always possible, Kehl said, leaving the units short-staffed.

In some weeks, Kehl said, the hospital would bring in 17 new contractors while losing 12 others. Some medical providers expressed gratitude for the traveling staff but also said that the high turnover put strains on training and the quality of patient care.

“Everyone is out there for the patients,” Kehl said. “But they’re the ones who suffer in the long run. When there’s not enough staff out there to cover, the patients are the ones who suffer. No one else.”

Many hospital staff who spoke to MTFP said they support the goal of recertification and are deeply invested in the facility’s overall success. But several also voiced a nagging fear born of the recently chaotic work environment. The current reforms may not be meant to set the hospital up for success, they said, but rather to intentionally destabilize the institution to justify its closure or privatization.

“The only way people can make sense of the actions of these quote-unquote leaders is to say that the whole purpose is to scuttle the place. Is to destroy it,” said a medical provider who requested anonymity. “I don’t buy that, but that’s what people are saying.”

“Everyone is out there for the patients. But they’re the ones who suffer in the long run. When there’s not enough staff out there to cover, the patients are the ones who suffer. No one else.” 

Pam Kehl, former staffing manager, Montana State Hospital

That same employee said that, at least hypothetically, the administration still has time to reverse course. Leadership, they said, could begin listening to employees, addressing their concerns and advocating for the investments the clinicians are seeking: the ability to order 1:1 staffing, the tools necessary to do their jobs, and an avenue to provide feedback without fearing reprisal. 

Other current and former staff said that, unless the relationship between administrators and staff improves, achieving recertification from CMS is unlikely.

“Recertification would give the hospital back the credentials it needs to have. I agree with that,” Kehl said. “But from what I’ve seen, the turnover of people is so high, I don’t see how they’d even get recertified. Not if things keep going the way they are.”

“They kind of burned their bridges for local staff,” said Robinson, the former staffing supervisor, referring to the hospital’s administration. “They have such a bad reputation for how they treat their employees that no one wants to work for them.”

Robinson is currently out of work and doesn’t know what will come next. She doesn’t plan to return to the state hospital or apply to any other state facilities. 

There have been difficult parts about leaving, Robinson reflected, including stepping away from a job she cared about. But ultimately, she described her exit as “a relief.” 

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