On Oct. 1, the Centers for Medicare and Medicaid Services (CMS) conducted a follow-up visit to the Brattleboro Retreat after previous inspections in June and August revealed conditions that jeopardized patients’ safety. Staff interviews and record reviews at that time found the hospital not to be in compliance with “Conditions of Participation: Governing Body, Patient Rights and Quality Assurance/Performance Improvement,” according to the CMS survey report.
Brattleboro Retreat developed a Plan of Correction that addressed three specific issues: a patient who had wrapped an elastic bandage around the neck; an unattended patient who attempted to drown in a bathtub; and a patient who left the grounds without authorization.
The plan includes a reorganization of the Quality Department, removal of “Spandage” type dressings from all units and continuous visual observation among other measures. CMS accepted Brattleboro Retreat’s Plan of Correction on October 16, 2014.
Rep. Anne Donahue, J.D. (R-Washington-2), editor of Counterpoint, which is published by Vermont Psychiatric Survivors, notes that more important than the Plan of Correction is the “System Improvement Agreement” from CMS.
“Up to this point, I think the ongoing problem has been that the Retreat was narrowly reactive to each previous problem that came up, addressing only the specific problem that arose and often blaming outside factors, instead of looking at its own hospital-wide systems. CMS was citing issues that were clearly systemic,” she says. “At the same time, the state Department of Mental Health was not holding the Retreat accountable for standards of care, despite the number of patients in state custody being cared for there.”
Donahue notes that in an April news release the Retreat spoke about its “unprecedented growth over the past six years,” including an increase in the number of staffed beds from an average of 50 in 2006 to an average of 122 in 2014. “This has been part of its apparent effort to create specialty inpatient units as a means of maintaining relevance in a type of hospital that is a dinosaur in terms of current, state-of-the-art care,” she says, explaining that the Retreat is in reality a rural, freestanding, non-medically-integrated, highly institutional setting.
“It went through those expansions while also cutting clinical services to save financial resources, and it has successfully stabilized its budget, now ranking as the 14th largest in the country from a revenue perspective. As the CMS reports over the past several years have demonstrated, however, quality has suffered as a result. I think the priorities were in the wrong directions.”
Donahue believes the System Improvement Agreement from CMS is a positive step toward sustained improvements in internal quality oversight. However, she questions the CMS standards as being useful for creating an adequate standard of care versus a minimum threshold. “The most obvious example is the amazing reality that CMS does not require a 122-bed hospital to have an MD on the premises 24/7 – and the Retreat does not provide this basic coverage,” she explains.
“I think one of the more discouraging issues to reflect upon is the reaction of state government. The administration said it would be a crisis if the Retreat lost CMS credentials because of the money it would cost the state in lost federal funds, having to make up the difference for patients in state custody or being reimbursed through Medicare or Medicaid. I thought the crisis was that persons were at risk of harm as a result of the failure to meet safety and treatment standards. So I think the problems at the Retreat are philosophical as well as structural,” Donahue says.
Attempts to reach Brattleboro Retreat for comment were unsuccessful.