State Agencies Release Audit Findings on Mind Springs Health and West Springs Hospital

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Findings include a wide range of issues related to quality of care

Colorado Department of Health Care Policy and Financing logoColorado Department of Human Services logoColorado Department of Public Health and Environment logo


May 12, 2022

Media Contacts
Marc Williams
Colorado Department of Health Care Policy & Financing

Mark Techmeyer
Colorado Department of Human Services

Peter Myers
Colorado Department of Public Health & Environment

Webinar Recording from the May 12, 2022 tri-agency public meeting on the Mind Springs audit findings

Denver, CO - Today, the Colorado Departments of Health Care Policy & Financing (HCPF), Human Services (CDHS) and Public Health & Environment (CDPHE) released audit findings following the tri-agency audit of Mind Springs Health and West Springs Hospital conducted in January 2022. The audit was prompted by multiple complaints received by the state agencies despite a corrective action plan already in place with Mind Springs following an April 2021 audit which found several quality of care deficiencies. The ongoing complaints came from several community members who cited difficulty accessing behavioral health services and a lack of transparency from Mind Springs.

Each state agency has specific authorities relative to Mind Springs. The objectives of the January audit were to:

  • Identify and address quality of care issues through recommendations and corrective action plans, 
  • Determine whether Mind Springs’ performance is meeting the behavioral health needs of Coloradans in the communities it serves and under its contracts with state agencies, and 
  • Provide additional recommendations and corrective action plans to address any new gaps and concerns with Mind Springs’ performance.

“The collective goal of our audit was to identify and address underlying root causes of Mind Springs’ performance challenges to the betterment of the health and well-being of the communities Mind Springs serves,” said HCPF Executive Director Kim Bimestefer. “Coloradans need access to reliable, quality behavioral health care. Audits like this are one lever we are employing to hold our behavioral health safety net providers, like Mind Springs, more accountable to meeting those needs.”

HCPF’s portion of the audit was largely conducted by Rocky Mountain Health Plans (RMHP) acting in its capacity as the Regional Accountable Entity on behalf of HCPF. RMHP identified issues with Mind Springs’ performance that compromised service to the community and required corrective action plans to address related gaps. These issues and related corrective actions include:

  • Safe Prescribing - to include closing nine outstanding gaps in the corrective plan, all of which pertain to prescribing practices and to implement the OpiSafe™ tool, an integrated prescription utilization tool that helps prescribers avoid over-prescribing, misuse and abuse of opioids, fentanyl, benzodiazepines, and other controlled substances.  
  • Reformed board structure, transparency, and community access - to include a revised Board of Directors governance design that improves community need awareness, balanced community representation, responsiveness, and transparency and provides related powers and duties sufficient to control the activities of all legal entities owned and operated by Mind Springs Health.
  • Access to care measurement and tracking - to ensure clinical services are delivered, promptly and in a culturally responsive form, following any request for care.
  • Access to care - to include a documented plan to close any gaps in contractual access to care standards and to include monthly reporting of gaps in frontline clinical, administration and leadership staffing gaps and related plans to close those gaps in care access, management support and accountability.
  • Compliance with revised cost reporting requirements to improve transparency and financial accountability - to include documented training and implementation plans to utilize modernized HCPF cost reporting, effective May 2022, which will improve transparency into Community Mental Health Center (CMHC) funding and costs, including Mind Springs.
  • Medicaid staff reporting requirement to create transparency in meeting community needs - to include development of a plan and submit quarterly reports on Medicaid staffing that details staff by county who are actively serving Medicaid members.
  • Address the five themes voiced by Mind Springs employees - to improve Mind Springs ability to meet community needs and to include: barriers to care; administration efficiency; leadership accountability; collaboration and transparency; staffing and wages.

The CDHS portion of the January audit found violations in critical incident reporting, release of information, service planning, discharge summaries, and necessary signatures. This resulted in a commitment to increase the frequency of internal audits, and a requirement for Mind Springs Health to complete action plans to address all violations and deficiencies to the betterment of the care, health and well-being of the communities Mind Springs serves.

The Colorado Department of Public Health & Environment was unable to substantiate any allegations of agency failures. There was insufficient corroborating evidence to establish with certainty that the allegations occurred; therefore, no deficient practice was cited. The attached report summarizes CDPHE’s investigative findings and comments. All inspection results can be found on the CDPHE website.

The Departments will continue to conduct audits to measure Mind Springs’ performance, while meeting no less than monthly with Mind Springs’ leadership. The Departments will also host quarterly meetings with community leaders to provide updates on Mind Springs’ corrective actions, performance and operations transformation to better meet the behavioral health needs of the communities it serves.

After years of foundational planning, community engagement, data and policy analysis, 2022 will go down in history as an unprecedented year for Colorado behavioral health investment and transformation. To Coloradans, this means meaningful improvements in behavioral health access to care, quality outcomes, health equity, prevention, treatment, recovery and more.


About the Colorado Department of Health Care Policy & Financing: The Department administers Health First Colorado (Colorado's Medicaid program), Child Health Plan Plus, and other programs for Coloradans who qualify. For more information about the Department, please visit