In response to a complaint, the Vermont Division of Licensing Protection completed a survey on Feb. 21, 2013 to determine if the Brattleboro Retreat met the Conditions of Participation for Psychiatric Hospitals.
Peter Albert, senior vice president of Government Affairs at the Retreat says, “After an on-site survey in February by the Center for Medicare and Medicaid Services (CMS), the Brattleboro Retreat received a letter on March 13 citing deficiencies. The Retreat has submitted a Plan of Correction and CMS conducted a follow-up survey the week of April 15. We are awaiting the CMS report in response to the Plan of Correction and follow-up survey.”
Courtney Jenkins, Boston Regional Office press contact for the Centers for Medicare and Medicaid Services, provided a redacted version of the statement of deficiencies and plan of correction. The investigation was conducted over a seven-day period in response to 14 complaints spanning 10 months.
The statement notes the hospital’s “failure to respect patient’s right to refuse treatment, failure to promote and maintain a physically and emotionally safe environment, failure to implement appropriate use of restraints and/or seclusion in accordance with federal requirements and facility policy and failure to report allegations of mistreatment in accordance with state and federal requirements.”
The survey revealed improper documentation, including improperly filed and out of sequence Certificate of Need for Emergency Involuntary Procedures, physician orders, progress notes and other pertinent information. In late March 2013, the Retreat did implement new documentation flow sheets for neurological, respiratory, cardiovascular, musculoskeletal and integumentary systems.
According to the statement, the hospital must use data collected to “identify opportunities for improvement and changes that will lead to improvement.” Also the hospital must prioritize performance improvement activities that “focus on high-risk, high-volume, or problem-prone areas; consider the incidence, prevalence and severity of problems in those areas; and affect health outcomes, patient safety and quality of care.”
Once these actions have been implemented, the hospital must “measure its success, and track performance to ensure that improvements are sustained.”
The plan of correction indicates that the chief medical officer, in collaboration with the Brattleboro Retreat’s attorney and other staff, addressed the deficiencies, including revision of the policies for Emergency Involuntary Medication, Observation Levels/Safety Levels and other areas noted in the survey. All staff has been educated in the new protocols and will conduct regular audits in all units.
The Brattleboro Retreat’s Albert says, “Our recent growth as a hospital has been accompanied by a process of continuous learning, problem solving, creativity and innovation. We remain focused on excellence in our clinical practice at all levels of the organization to assure that we are providing exceptional and compassionate care to our patients. We are confident that we will correct all cited deficiencies and make all necessary improvements.”
The Retreat filed a plan of correction on April 24, 2013, which was accepted by the Vermont Department of Disabilities, Aging, and Independent Living.