Feds Sanction Mental Health Facility in Vt.

Brattleboro Retreat Is a Key Hub In the State’s Psychiatric System

The Brattleboro Retreat, Vermont’s largest psychiatric facility, is in trouble with the federal government again, and state mental health officials are 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.

Retreat officials are scrambling to submit a plan of correction to the federal agency by today (the hospital was granted an extension to do so).

The private nonprofit hospital must then prove to CMS 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, Vt., for about 25 patients.

The retreat is 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 spokesman 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.