By Phillip Reese and Cynthia Hubert, Sacramento Bee

Federal investigators said Wednesday that a Nevada state psychiatric hospital under scrutiny for busing roughly 1,500 patients to other states in recent years “failed to provide an appropriate safe discharge plan for patients.”

The report from the Centers for Medicare & Medicaid Services lays out multiple instances in which Rawson-Neal Psychiatric Hospital in Las Vegas did not meet conditions for federal funding. Many of the deficiencies noted in the report relate to James Flavy Coy Brown, a homeless, schizophrenic man bused to Sacramento in February without family or shelter waiting for him.

The hospital, in response to the report, laid out a detailed corrective plan of action to address the shortcomings. CMS will study that plan to determine if it is adequate. If not, the facility could lose Medicare funding.

“The review process is just starting,” said CMS spokesman Daniel Hersh. “It won’t be instant.”

The report found that the hospital “failed to ensure a comprehensive discharge plan was implemented” and that it “failed to identify patients who were likely to suffer adverse health consequences upon discharge without an adequate discharge plan.”

“The cumulative effect of these systemic practices resulted in the failure of the facility to deliver statutory mandated care to patients,” the report said.

In their response, Rawson-Neal officials said the hospital has implemented “a 100 percent review” of every discharge to another state by two medical staff members and the hospital’s administrator. They also said they had reviewed and updated all discharge and medication consent policies.

CMS is one of several organizations investigating Rawson-Neal in the wake of a Bee investigation into the hospital’s discharge practices. Others include an independent accreditation organization and the cities of Los Angeles and San Francisco.