Published on Jun 06, 2024
Acadia Healthcare’s (ACHC) network of opioid treatment facilities, known as Comprehensive Treatment Centers (CTCs), are operating at staffing levels far below what is required by regulators in several of the states in which they operate, a Capitol Forum investigation has found.
In particular, Acadia’s CTCs have been cited dozens of times by state inspectors for having insufficient numbers of addiction counselors and for not providing the minimum amount of counseling to patients.
Addiction counselors provide one-on-one and group therapy and states generally require clinics to keep their patient-to-counselor ratios below 50:1, though that number varies from state to state and can be higher. Additionally, clinics are required to provide a minimum amount of therapy time to every patient receiving methadone, which also differs from state to state.
However, Acadia’s CTCs are continuing to dose patients with methadone despite not being physically able to provide that minimum amount of counseling.
According to former CTC employees in several states across the country, Acadia knew that it had a problem with staffing but continually pressed CTCs to enroll more patients while maintaining staff levels and even cutting counseling staff.
A former clinical supervisor in California, where the state requires Medicaid patients to receive a minimum of 50 minutes of counseling per month, told The Capitol Forum that “patient to counselor caseloads were always way too high, but we couldn’t hire more counselors. Even if we were fully staffed, the goal was to grow the patient population every month. We got a bonus for increasing patient population numbers, but they weren’t increasing number of counselors or case managers. Caseloads started going to going from 50 to 60 to 70 to 80 to 90 to over 100, which is impossible.”
Former employees in other states also said that their CTCs sometimes had double the state limit for patient-to-counselor ratios, which meant that it was hard for counselors to correctly document the minimum necessary number of hours for their CTC to bill for the patient’s treatment. In some cases, former employees said, that meant that strained counselors sometimes made up therapy sessions to hit their quotas or documented sessions as being much longer than they actually were.
“I have been in substance abuse counseling for twenty years, and I have never worked somewhere like Acadia’s CTCs, where the focus was just entirely on your production and profits,” a substance abuse counselor in Wisconsin said. “A lot of these patients needed actual, real therapy, I could tell they needed help, but our priority was to just push them through the system for billing. It was just talk to them for 10-15 minutes, bill for an hour, and send them out on the street to use again. The whole person isn’t looked after, it was rinse and repeat with everyone.”
A recent whistleblower lawsuit in North Carolina by a former assistant medical director alleged similar violations at an Asheville CTC. According to the complaint, Acadia has “engaged in systematic and widespread fraud by falsifying group therapy treatment notes and providing inadequate counseling and therapy for patients in drug treatment.”
According to the complaint, staff at the Asheville CTC fabricated patient notes and records for group therapy sessions that never occurred, and “counselors and therapists copied and reused the same falsified group therapy notes for different patients.”
“Upon information and belief, this method of falsifying group therapy records is a corporate policy that has been implemented in facilities owned and operated by Defendants across the country,” the complaint claims.
That case was dismissed after a court found that the whistleblower hadn’t specifically cited false claims that had been presented to the government for reimbursement and established that the fabrication of notes was a widespread practice across the company, among other things. That dismissal is currently under appeal.
Acadia CTCs have continued to provide patients with methadone and billed Medicaid for opioid disorder treatment despite not being able to provide the necessary counselors or counseling time. Last week, The Capitol Forum reported that CTCs were violating other state requirements of opioid treatment programs, including providing proper oversight and monitoring of patients.
Acadia did not respond to a request for comment for this article and questions regarding counselor caseloads, but the company previously told The Capitol Forum that “our treatment programs include comprehensive care – such as one-on-one counseling, individual and group therapy, and other evidence based support – to help patients live their lives free of illicit drugs.”
Caseloads exceed maximums in several states. The Capitol Forum received inspection reports of CTCs from regulators in their respective several states through public records requests and online databases. Those reports show that CTCs across the country have been routinely and repeatedly cited for having staffs of counselors far below what would be required for the number of patients at the CTC.
Those reports also show that Acadia CTCs can be much more understaffed than other treatment centers. As The Capitol Forum previously reported, Acadia drug treatment centers in Pennsylvania were twice as likely to violate the state’s limit of 35 active clients per counselor compared with the state average.
According to a former case manager in Pennsylvania, “we had about 800 patients, four counselors, one case manager, and one physician. At one point we had two dosing nurses but when I left it was only one that could dose every patient.”
In other states, Acadia has similarly failed to maintain patient-to-counselor ratios below the state maximum.
In Kansas, the Wichita CTC has been cited multiple times over the last three years for failing to show “evidence that a counselor had 50 or less client equivalents” and in Mississippi, the Jackson CTC has been cited because “the counselor to person ratio exceeds the maximum allowed.”
Former employees also said that it was not uncommon for patients to be shuffled around both within the CTCs and to nearby CTCs in order to make counselor-to-patient ratios appear lower. According to a former clinic director in North Carolina, “what they typically do is go in and shuffle individuals around. They would take some of those individuals and sub them under the regional director and make the regional director a counselor, people that never visit the clinic and who the patients have never seen. We got very shifty with multiple counselors and providers throughout the state.”
Indeed, inspection records from North Carolina CTCs indicate that patients were being placed under doctors and administrative staff rather than substance abuse counselors. At the Pinehurst CTC, for example, regulators found that there were 444 patients but only 6 substance abuse counselors—this ratio of 74 patients per counselor far exceeds the state’s maximum of 50 patients per counselor.
Inspectors found that, on top of their medical and administrative duties, “the Clinic Director had a caseload of 60 clients [and] the Clinical Supervisor had a caseload of 60 clients.”
While many of the former employees said that staffing counselor jobs could be difficult, they also said that Acadia did not prioritize hiring counselors and kept counselor pay low relative to other treatment programs.
According to a former clinic director in Maine, state requirements for a “substance abuse counselor case load were 35 and for an LADC [Licensed Alcohol and Drug Counselor] they were 55, but we were running caseloads of 100 and 115. Acadia kept making us apply for waivers to those case load maximums and to do so we had to show the state we had positions posted for hire. But when people applied, we had to do everything through corporate for some reason, and it was a painfully slow process unless they knew we desperately needed someone.”
“I would ask ‘What’s the hold up? I need this person.’ And corporate would say, ‘Why? You’ve got a waiver and you are at 95 cases per counselor, you can make do with that.’”
Those high caseloads combined with the low pay created a vicious cycle, according to former employees, because new counselors would quickly feel burnt out and quit, further exacerbating the staffing shortages.
“I was hired as a counselor on the spot,” a substance abuse counselor in Wisconsin said. “I found out that right before I came to apply, four counselors had walked out. I learned pretty quickly that that was a common theme at CTCs. I only lasted about four months and then I walked out with a few other counselors as well.”
A substance abuse counselor in Kansas, whose first job in the industry was with Acadia, told The Capitol Forum that “within two weeks, I had a case load of 50 people because someone who had been there 3 months quit and I got a lot of her patients. Other people that had been there a long time had 70 or more people.”
“I apparently got 50 easy people, but even with the required contacts, 50 people is a lot even for an experienced person and not someone fresh in the field,” the former substance abuse counselor added.
Underqualified counselors. In many states, opioid treatment program can hire substance abuse counselors with no qualifications so long as they are working towards a degree and the program is providing support and training for the uncertified counselor. Much like the substance abuse counselor above who was immediately given 50 patients, former employees at Acadia told The Capitol Forum that their CTCs routinely hired uncertified counselors, gave them high caseloads, and failed to provide appropriate support.
According to the former clinic director in North Carolina, “the way it should work, the new counselor comes in and you get on the job training but you’re not supposed to be providing counseling services. We ran into many issues where that person with no background is providing counseling and making the situation worse because there was no oversight with them. There was really just no oversight of them at all.”
“We would blindly give certifications to submit to the state to say they’ve completed the training with us, but there was really nothing we did for them. People knew they can come to us and get a certification signed off on and then go elsewhere,” the former clinic director added.
According to a former substance abuse counselor who went through training at a CTC in Nevada, “supervision was more group supervision, not individual. For interns that is unacceptable, especially considering they had interns running group therapies without any real supervision.”
Asked if they received proper supervision during their time as a counselor in training at the CTC, the former employee responded “Absolutely not. I asked for individual supervision but didn’t get it. I needed more one on one.”
The former intern said that they were ultimately fired because of a mistake they made with a patient’s chart, a mistake that the intern said was “caused by a lack of supervision.”
“In California, you have five years to get certified. Think how much damage could be done,” a former clinical supervisor in that state said. “You could be anyone of the street saying you wanted to be a counselor, and there was no ability to provide direct supervision. They could be saying whatever to the patient and it would be very difficult to provide the direct support needed because we were so short staffed to begin with.”
Inspection records from several different states confirm that CTCs had a problem with providing the kind of supervision to unqualified counselors as required. At the CTC in Medford, Oregon, for example, an inspection in 2022 found that “one out of three supervision records reviewed did not contain sufficient documented evidence of the required one hour of monthly individual face-to-face supervision.”
Patients not receiving the required amount of counseling. In order to be on a methadone treatment plan, patients are generally required to undergo a set amount of counseling per month, the amount of which can vary from state to state. Regardless of their respective state’s requirement, however, many former employees said that their CTC was unable to provide that minimum level of counseling because of the staffing shortage.
Acadia CTCs across the country have repeatedly been cited for not providing the required amount of counseling, which may be unsurprising given the number of citations for low staff.
At the Canton, OH CTC, for example, regulators found during a January inspection that “in 2 of 2 patient records reviewed, counseling sessions were not provided at least weekly for the first 90 days of treatment and for at least 50 minutes in duration.”
Even when patients could see counselors, the high turnover among Acadia counselors meant that it could be hard for patients to open up to them.
“I heard from patients who said it’s hard to open up to you because I know you will be leaving soon, and that was before I considered leaving,” the former substance abuse counselor in Kansas said. “Some patients told me they had 5 or 6 counselors in one year. A lot of them believed that we didn’t care, that their counseling was just a requirement to be met for Medicaid billing. Some patients did truly want the counseling, but you didn’t have the luxury or time to do so.”
“I realized I didn’t want to be there either, because I wanted to spend time with my clients and didn’t feel that was a good fit for me. It just felt like it was medication management not treatment or counseling,” they added.
Some former employees of Acadia CTCs said that, when state inspectors discovered lapses in required counseling sessions, their CTC managers sometimes tried to blame patients for the failures and have staff cover for the clinic’s shortcomings.
According to the case manager in Pennsylvania, when the state’s Department of Drug and Alcohol Programs inspectors came for an audit, they found “discrepancies in session notes that were written and I was asked to sign a statement that was a lie and to lie to a DDAP auditor.”
“We were deficient in counseling hours, and my manager wanted us to say that the patients were delinquent in meeting with us. But patients were literally dying to meet with us. They were trying to make it seem like the patients were the ones not seeing us.”
Regulators in other states have caught CTC staff trying to blame missed appointments on patients in recovery when a lack of staff and multiple counselor reassignments were to blame. In 2022, inspectors at the Lynchburg CTC in Virginia found that a patient had missed several months of counseling and tried to determine the cause.
According to the report, “in the treatment plan review dated 4/15/22 for Individual #1, compliance is determined by the individual’s actions, not the clinic’s actions.”
“[Individual #1] demonstrates compliance with individual and group counseling appointments, however [individual #1] has been reassigned for counseling multiple times which has impacted his ability to fully engage in counseling services. Despite the lack of counseling, [individual #1] remains motivated to progress with treatment goals and to make long-term changes to his life which support treatment and recovery.”
“Thus, we reject the claim that there was a ‘failure of an individual to participate in counseling sessions.’ Individual #1 fully engaged in counseling every time it was offered to him and clearly and appropriately communicated his needs to the counseling staff. He worked tremendously hard in treatment for 25 months at that point, providing 24 months of non-illicit drug screens and treatment compliance. We submit that blaming Individual #1 for a global pandemic and related staffing issues would be excessive and needlessly harmful to Individual #1.”
While CTCs have struggled to provide individual, one-on-one counseling, former employees say that group therapy can also be hard to come by.
According to the former substance abuse counselor in Kansas, patients in that state are required to go to two group therapy appointments per month in order to receive take home doses of methadone. Their CTC, however, did not have enough staff to allow for accessible group therapy sessions.
“To get take home medication, there are several requirements, and one is going to two group sessions a month. But those group hours are really unaccommodating. They are really infrequent and held at hours when you are supposed to be at work. Some people went to AA three times a week and couldn’t do the group therapy we were offering. So even if they passed their urine and everything else, they couldn’t get take homes and would have to come in and dose daily.”
“People said that made it feel like they were chained to the center,” the former counselor added.
Former employees in other states told The Capitol Forum that group sessions were similarly infrequent at their CTCs and, in some cases, barely qualified as group therapy at all.
According to a former clinic director in North Carolina, “when I came into that clinic, there was only one set of groups being done, and it was called ‘Flapjack Friday.’ Patients came in, staff cooked pancakes, and they walked out the door. That was being billed as group therapy.”
Some counselors falsified sessions to meet therapy quotas. The former employees who spoke with The Capitol Forum said that substance abuse counselors at their CTCs had a requirement to document the state minimum amount of therapy time every month. However, because of high caseloads, many counselors were unable to meet this minimum level of counseling.
A former clinical supervisor in California told The Capitol Forum that in that state, “each patient was required to have about 50 minutes of counseling each month. There are just too many patients and some of these patients you just can’t track down to do the counseling, you don’t have the time.”
“At the end of the month, I sent out the under-counseled list, and that was added pressure on the counselors, and I know some counselors would make up counseling sessions to meet that quota. It was unethical, but they were almost forced to do that because there weren’t enough counselors.”
“One had notes saying she did a session with a patient who had died the day before in a car crash. When they found that out, they fired her. I get the reason she did that. It was towards the end of the month, and she didn’t want to be under quota. But with a 90-patient case load, it’s impossible to hit that without being unethical.”
According to the former clinical supervisor, substance abuse counselors had daily quotas in addition to their monthly quotas. A 10-minute counseling sessions was broken down as one unit, they said, and counselors were supposed to have fulfilled 29 units per day.
“That’s almost five straight hours of counseling a day, and keep in mind counselors have a lot of other duties too, it’s not just talking to people. Treatment plans, ASAM, and discharge plans needed to be updated regularly. Plus, most counselors would be tasked with doing intakes, and an intake can take anywhere between ninety minutes to two or three hours. There were days when I had to do three intakes. It’s impossible.”
Other former employees in management said that their CTCs operated under a similar metrics, with 10-minute chunks of counseling counting as one unit and counselors having a quota of units. As in California, the high caseloads meant that counselors couldn’t authentically meet their quota, leaving some managers feeling that sessions had been falsified.
According to a former director in Maine, their CTC “could not meet the monthly requirement for counselor sessions. If counselors didn’t meet their goal, they wanted us to write them up for not hitting their units and directors were bullied.”
Asked if counselors ever made-up sessions, the director responded that “I suspected that that was going on. I called up a couple different counselors. Although I didn’t accuse them, I asked them how they could have met these quotas if they were so far off the beginning of that week. I could not prove beyond a shadow of a doubt that’s what went on, but I believe that happened.”
“Writing up a new counselor who isn’t able to see 100 patients in a month isn’t right,” the former director added. “And it’s not good teaching, we’re not teaching people how to be good clinicians, we’re just teaching them how to hit numbers.”
While some counselors denied making up therapies entirely, several told The Capitol Forum that they documented short therapy sessions as being longer than they were in order to hit their quotas and meet the state minimum.
To meet their quota, a substance abuse counselor in Wisconsin said that they were “jumping out of my office to grab people in the waiting room whenever I saw them. Even if I only had five minutes to chat with them, I billed that as a half hour.”
