Off and on for the past three weeks, the staff at Pinellas County's crisis unit has been breaking the law by packing more patients in than its license allows. And state officials charged with enforcing the law have been looking the other way because they know the staff has no choice.
"I'm not saying it's okay to break the law. I'm saying the alternative may be worse," said Martha Lenderman, Pinellas-Pasco mental health chief for the state Department of Health and Rehabilitative Services (HRS).
Cots and mattresses have been brought in to handle the overflow of suicidal and psychotic patients, said officials at Pinellas Emergency Mental Health Services. Extra employees have been brought in, even though there is no money in the budget to pay for them.
The agency receives its funds through a contract with HRS to handle Baker Act patients _ those who are dangerous to themselves or others.
The glut of patients goes beyond the usual seasonal fluctuations, said Paula Pressler-Tash, director of adult services. Until recently the agency could place extra patients at area hospitals that have psychiatric units, but a 5 percent state cut in the agency's $60-million budget last fall has wiped out money to pay those bills.
It costs at least twice as much to keep patients in hospitals as it does to treat them in crisis stabilization units.
While some of the patients qualify for Medicaid, hospitals are not eager to take them. Morton Plant, which does, gets only about 39 cents on the dollar _ less than it costs to care for the patients, said Dr. John Babka, the hospital's director of medical affairs.
Pinellas Emergency Mental Health Services (PEMHS, pronounced "pims") has been working feverishly to stabilize patients enough to send them home or transfer them to less-structured programs. But if that is not possible, the extras are fitted in.
"If you've got a lifeboat with a capacity of 18, and you've got 18 in the lifeboat and three in the water, you're going to pull them into the lifeboat," said state Rep. Jim Frishe, a Pinellas Park Republican who serves on the PEMHS board.
This policy contrasts sharply with what has been happening in Hillsborough County, where the crisis unit will take only the number of patients for which it is licensed. The rest are placed on waiting lists.
In the past, these patients ended up tied to gurneys in hospital emergency rooms for days. Sometimes they rode in the backs of police cars for hours as officers tried to figure out what to do.
Newspaper articles about this practice generated enough pressure to open up more beds in Hillsborough, Lenderman said. The squeaky-wheel syndrome doesn't work in Pinellas, she said, because PEMHS does not turn people away.
According to HRS records, the Pinellas-Pasco district is near the bottom in per capita state financing for emergency mental health services, while Hillsborough County is near the top.
And the disparity likely will increase. The district that includes Hillsborough has received preliminary budget approval for 30 more beds, Lenderman said, while PEMHS' request was turned down.
"We wish we could have had enough money to fund them," said Laura Brock, a budget analyst in the governor's office. "They do a lot of good things."
PEMHS' crisis stabilization unit, which is temporarily housed at Horizon Hospital in Clearwater, is licensed for 29 beds but as of Monday morning had 32 patients, said Pressler-Tash.
An acute-care unit at PEMHS headquarters, 11254 58th St. in Pinellas Park, was licensed for 13 patients but had 15; the unit at 401 16th St. N in St. Petersburg was at capacity with 15; and a children's unit at headquarters that should have had only 10 patients had 13.
The Pinellas request that did not make it through the governor's office was for more children's beds.
MHC Inc., the Hillsborough agency that handles Baker Act patients, has four children and five adults on its waiting list, according to Director Ron Mihalick.
It is not a good idea for crisis units to go beyond their licensed capacity, he said, because the staff becomes overworked, the public is deceived and the patients do not get enough attention.
"It presents an illusion that they're being taken care of," Mihalick said.
HRS' Lenderman strongly disagrees with that stance. She said she insisted that the contract with PEMHS require the agency to take all comers _ a policy that PEMHS officials said they would have adopted anyway.
That would seem to place HRS' Vince Smith in an awkward position _ he is supervisor of the department's office in Tallahassee that inspects crisis units to make sure they are not overcrowded. But Smith agrees with Lenderman. Under the circumstances, he said, PEMHS is behaving responsibly.
"We're not going to be technocrats," he said. "We want to enforce standards, but we want to enforce them reasonably."