KSHB 41 reporter Ryan Gamboa covers Miami County in Kansas and Cass County in Missouri. He also covers agricultural topics. Share your story idea with Ryan.
In December 2024, the Kansas Legislative Division of Post Audit (KSLPA) released a report highlighting safety and security concerns at the Osawatomie State Hospital.
The audit was requested by five Kansas legislators, Rep. Samantha Poetter Parshall (R-KS Dist. 6), Sen. Caryn Tyson (R-KS Dist. 12), Rep. Carrie Barth (R-KS Dist. 5), Rep. Fred Gardner (R-Dist. 9), and former Sen. Molly Baumgardner (R-Dist. 37).
"The legislative post audit was an opportunity to see what are the things that we perhaps need to shore up," Secretary Laura Howard told KSHB 41. "I appreciate the opportunity for reviews."
The Kansas Department for Aging and Disability Services (KDADS) is the direct department overseeing operations at the Osawatomie State Hospital (OSH).
Established in 1863, the state run facility has provided inpatient psychiatric and mental health services. The state of Kansas operates two psychiatric care facilities. On the OSH campus are two independently operating hospitals, the Osawatomie State Hospital and Adair Acute Care (AAC).
Over four years, KSLPA surveyed current and former employees to understand safety concerns better.
"I was pleased to see in the survey, that post audit did, they could really see that difference under the current management," Howard stated.
State auditors found current employees offered favorable ratings to OSH's new administration.
"We’ve had Superintendent Byram in place for two years now," Howard said. "The audit showed me that she is really making some positive progress in terms of the culture of the organization."
The audit still revealed that processes and procedures at OSH fell below its standards, highlighting physical security, personnel, and workplace culture.
The auditors sampled documentation data from January 2022 to September 2024 and surveyed current and former employees from state and contract employees from fiscal years 2020 to 2024.
Initial findings claim that OSH does not have adequate processes to ensure physical security. It found security staff patrols at the OSH campus are incomplete and inadequate.
Security staff is responsible for checking non-patient facilities' exterior doors to ensure they're locked, outside business hours.
It was reported security staff patrols were frequently incomplete.
Additionally, KSLPA found OSH does not ensure staff carry required personal safety alarms, and fails to check if staff responds to alarms in an appropriate time frame. Later in the audit, it was reported former and current staff experienced physical and verbal abuse from patients.
"My presumption would not be that because some of these things are not really around policy procedure, both documentation and practice," Howard said. "That when you put those things together Osawatomie isn’t safe. We have passed all our federal certification surveys. What it did tell us though is that it can do better."
Howard told KSHB 41 that many of its immediate changes post-audit have been implemented.
"Key control...that's all that's a challenge always in big institutions," Howard added. "One of the things that we'd already started at Osawatomie was putting more key card control in place as opposed to maybe having as many keys around there."
With 25 buildings on the hospital campus, most have physical key access. Auditors noticed OSH identified at least 56 keys as stolen, including keys granting access to patient units, and many other keys including 8 grand master keys as lost.
"They're already looking into maybe a better solution than just having better documentation of when keys are checked in and out," Howard explained. "My team has clearly called out a very specific plan to do that and I have a lot of confidence that will take place.”
For staff working directly with patients, KSHB 41 tracked down former OSH Mental Health Technician, Jamie Reavis. The lifelong Osawatomie, Kansas resident worked with patients from 2021-2022.
"I’ve been working in Mental Health since I turned 18," she told KSHB 41. "It’s a big deal down here."
The hospital has 533 total authorized positions at OSH including full-time equivalent and part-time roles.
Detailed in the audit, Reavis' position had the highest turnover rate in 2024 at 79%.
"It's the most dangerous job," Reavis explained. "We're out there with the patients. We are going into each of their rooms and for extended periods of time taking their vitals, checking on them, doing routine 15-minute checkups."
Reavis told KSHB 41, her job was often unpredictable.
"People would get punched or their hair dragged," she said. "We all really had to stick together, watch our patients, and watch each other team to make sure that that didn't happen.”
Reavis says alarms staff keep on their person often wouldn't ring loud enough to call for help. If the alarm was pressed into clothing or covered by a hand, she says it was practically useless.
"You got to be really safe when going to work," Reavis added.
Howard says there are numerous ways staff can call for help including an intercom.
She says the department could look into alarms that have potential GPS triggers that could allow support staff to know the location of and alarm response.
"I felt the pay was good," Reavis explained. "At the end of the day, how much money is worth getting beat up all day?"
The OSH's base operating budget, including Adair Acute Care, was $59.6 million in 2024. The audit outlined that $48.2 million (80%) was paid through the state's general fund while $11.5 million in Medicare funding was allotted to AAC.
"The individuals that receive treatment in Osawatomie who come from all across the state are our Kansas mothers, fathers, sons, daughters who need quality mental health services," Howard added. "When I think about use of taxpayer dollars, these are some of the most vulnerable citizens... this is a quality hospital. It provides quality care."
According to Reavis, she's speaking out with hope that processes at the Osawatomie State Hospital continue to change.
"It makes me sad. It makes me sad to see those people like that," she said. "I want to see people have success stories at the state hospital... It could be such a shining light here.
There is a lot to unravel in this story — KSHB 41 will continue to dive deeper into issues at OSH.
Out of the five legislators who requested the audit at OSH, only one agreed to a sit-down interview with KSHB 41. Another said they were too busy to discuss this issue. The remaining three did not respond.
If you're a current or former employee and would like to share your voice, email Ryan.Gamboa@kshb.com.
To read the full KSLPA audit on the Osawatomie State Hospital, click here.
OSH Supertendent Byram's response is at the bottom of the report.
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