Medicaid to terminate payments to Vermont psych hospital Aug. 15th

June 7, 2013

Brattleboro Retreat is in trouble with the federal government again, and the state is preparing for the worst.

The Centers for Medicare and Medicaid Services (CMS) says it plans to terminate payment for Medicare services on Aug. 15 because the Retreat is not providing adequate care for patients. It’s the fourth time in 18 months that the hospital has violated federal standards.

The Brattleboro Retreat, the largest psychiatric facility in the state, is scrambling to submit a plan of correction to the federal agency by Friday (the hospital was granted an extension to do so).

The private nonprofit hospital must then prove to the Centers for Medicare and Medicaid that it has taken actions to stem systemic problems at its sprawling campus in Brattleboro, which treats about 3,000 patients a year. Of that total, a few hundred are wards of the state.

Hospital employees surveyed by CMS said staff routinely restrained and secluded patients without cause instead of using other methods to de-escalate volatile situations and, in one case, a patient was forcibly medicated.

Nursing and mental health workers have not been adequately trained, according to documents from CMS.

The Retreat also failed to keep records on treatment plans, medical plans, psychiatric evaluations and therapeutic activities, among other required areas of documentation, in a sampling of patient charts, according to CMS.

As a result of the most recent violations of federal standards, the Retreat, which has an annual budget of $100 million, could lose federal funding for about a third of its patients. The potential cost to the state, which is using the Brattleboro facility as one of the main hubs of its regional mental health system, could be much greater. That’s because the state has already paid for construction upgrades and has nowhere else to put the 14 to 28 patients the facility is treating. The state is under contract to pay the Retreat $8 million a year.

The Vermont Department of Mental Health will immediately begin devising a contingency plan should CMS decertify the hospital and revoke funding, according to Mary Moulton, the acting commissioner. Moulton says the state must prepare for the possible closure of the Retreat. Between now and the next CMS inspection, the state’s quality services director for the department will provide technical support for Retreat officials two days a week.

“At this point, we are very concerned at the Department of Mental Health that the Brattleboro Retreat is able to submit a plan of correction that will be accepted by CMS for the various areas it needs to address, and there are numerous ones,” Moulton said.

The CMS sanction is for the entire hospital — not just the state’s level 1 unit — Moulton said. “Therefore the loss of federal dollars impacts the entire hospital and that includes the children’s unit where Vermont children are being served under Medicaid,” she said.

Since Shumlin administration officials abandoned the Vermont State Hospital in August 2011 when the facility was damaged by Tropical Storm Irene, the Retreat, Fletcher Allen Health Care and the state’s regional hospitals have cared for patients with severe psychiatric conditions. Instead of building a facility to house the 40 to 60 patients who need intensive psychiatric treatment at any given time, Shumlin and lawmakers agreed to build a “decentralized” system of regional care. Two years ago, the administration laid off about 80 workers from the state hospital who specialized in treatment for volatile patients and agreed to build a replacement facility in Berlin for about 25 patients.

The Retreat, a private hospital, which is now part of the new state system, has taken in the most state patients and has been responsible for evaluating “forensic” patients who have committed violent crimes and are subject to court-ordered treatment.

In an email, Peter Albert, the spokesperson for the hospital, alluded to the difficulty of treating state patients, many of whom experience violent episodes. The majority of the problems, he said in a statement, “are related to this new state hospital unit.” Since August 2011, the Retreat has admitted 5,385 patients, 331 of whom are state wards.

“To be very clear some of the issues are absolutely ours to fix, we own them and we are responsible for them,” Albert said in a statement. “However, where you can help is by recognizing that many of the issues relate to a system that although has seen progress, remains in crisis and that the only way to have lasting success is to address not just the Retreat but the system as a whole.”

A Retreat statement went on to blame the hospital’s problems on the “context” for the CMS termination letter. “We are operating within a mental health system that remains in crisis following the precipitous closure of Vermont State Hospital with 5 Department of Mental Health (DMH) Commissioners in 4 years, no DMH Medical Director to provide clinical support to the overall system, insufficient community support programs in place to discharge patients who are ready to move back to their communities, a lack of sufficient inpatient psychiatric beds, community hospital emergency rooms backed up with mentally ill patients, a lack of resources for forensic patients and a lengthy court process for involuntary commitment and medication procedures.”

Moulton, the interim commissioner who leaves at the end of the week, said in an interview there is “no doubt” the Retreat is taking patients that have a higher level of acuity that other hospitals will not take. There is, she said, a “level of challenge, working with people who have more violent episodes of behavior.”

“If it’s an employee problem it’s very hard for a whole staff to come up to a level to work with people they may not have worked with before so they absolutely do have those internal issues with staff,” Moulton said.

This isn’t the first time the Brattleboro facility has faced sanctions from the federal government. The Retreat’s problems with the feds began more than a year ago, when a young man, Jared Fitzpatrick, died of a drug overdose after he ingested methadone he took from a nurse’s cart. Since January 2012, state and federal officials have conducted five surveys of the facility. Dr. Rob Simpson, the CEO of the Brattleboro Retreat, neglected to mention the overdose or the ensuing CMS investigation and potential loss of federal funds in testimony before a Senate committee last year as lawmakers considered whether to pay for annual fees and a construction project at the Retreat for state wards. Simpson later apologized to lawmakers for his failure to disclose the information to the public. The Retreat made an effort to rectify problems with nursing staff and drug dispensing, and in August, CMS announced it would continue to fund the facility.

At the time, Simpson said he would provide lawmakers with information up front about incidents at the Retreat. But he and Albert have been less than forthcoming with regard to the latest CMS survey. The termination letter from CMS was received on May 20, but word didn’t get out about it until last Friday. As news broke of the Retreat’s new difficulties on Tuesday, Retreat officials were unavailable by phone and Simpson headlined a news conference — not about the CMS funding cutoff — but about a new mental health insurance claims initiative with Blue Cross Blue Shield, the Vermont’s largest health insurance company.
State patients are treated on the fourth floor of the Tyler Building on the Brattleboro Retreat campus. Photo by Randy Holhut/The Commons

State patients are treated on the fourth floor of the Tyler Building on the Brattleboro Retreat campus. Photo by Randy Holhut/The Commons

The latest revelations from a CMS survey in mid-April show that three staff members forcibly isolated, restrained Patient #15 face down and injected him or her with Zyprexa (the gender and names of patients are confidential). It is illegal to involuntarily medicate a patient in a non-emergency situation, and it is against regulations for a patient to be subjected to isolation unless he or she exhibits aggressive behavior.

CMS officials discovered that Patient #15, mentioned above, had been restrained and secluded two previous times even though the patient did not exhibit violent behavior, according to an observer cited in the survey. No reason was given in the patient’s chart for the seclusion.

In interviews with surveyors, a nurse said the actions were justified because she was afraid Patient #15 would assault her. The patient often “manipulated meds” and so when the patient ingested only half of a Seroquel pill and spat the rest back into a cup, the nurse asked for “mouth check.” Patient #15 refused and threw water in the nurse’s face.

The episode did not warrant restraint, seclusion or forced medication, CMS found. No reason was cited for the seclusion and no assessment was conducted afterward. Surveyors concluded that nurses and mental health workers at the Retreat have not been trained in protocols for restraints and seclusions.
Workers protest job cuts at the Brattleboro Retreat. Photo by Randy Holhut/The Commons

Workers protest job cuts at the Brattleboro Retreat. Photo by Randy Holhut/The Commons

In addition, CMS cited the Retreat for the following deficiencies in a sampling of 10 patient charts:

• Medical staff did not develop individualized treatment plans for patients;
• No psychiatric evaluations for intelligence, memory functioning and orientation were referenced;
• Substantiating psychiatric diagnoses were missing;
• Patients were not given individual treatment plans;
• No designated staff were given responsibility for treatment plans;
• Social workers were not involved in care of patients;
• The therapeutic services section of the chart was left blank.

The Retreat laid off all 31 therapeutic specialists in November, and nurses, who have not been trained, have been asked to pick up the slack. The Retreat offered therapeutic services training for its 175 mental health workers, but only 9 percent attended the training because it was not mandatory, CMS found.

The commissioner was critical of the Retreat’s documentation of patient care. Moulton described the deficiencies as a “systemic issue.” Getting the charts right, she said, is “just their business.”

“These are our patients,” Moulton said. “These are people who are in mental health crisis, and that’s what they do — they’re a psychiatric hospital.”

Source: Anne Galloway, "Brattleboro Retreat sanctioned for inadequate care, faces Aug. 15 cutoff for federal funding," VTDigger.org, May 29, 2013.