Brattleboro Retreat receives 'full compliance' review by fed
BRATTLEBORO >> Last week nine federal and state officials representing the Centers for Medicare and Medicaid Services completed a four-day survey of the Brattleboro Retreat. This was the unannounced full federal survey the Retreat had been anticipating for the review of all CMS Conditions of Participation.
"We are extremely pleased that the surveyors found the Retreat to be in compliance with all of the COPs," said Konstantin von Krusenstirrn, the Retreats's vice president of strategy and development. "A written report from CMS is expected sometime in the next two weeks but CMS has already indicated that it had not found any issues that would threaten the Retreat's certification status."
The surveyors reviewed all of the COPs, including areas related to patient rights; the Retreat's governing body; quality assessment and performance improvement systems; the medical staff; nursing services; and the hospital's physical environment. Within the COPs are scores of standards with specific requirements.
"We could not have achieved this success without the hard work and dedication of the Retreat's exceptional staff," said von Krusenstiern. "The federal surveyors expressed their appreciation for our clinical skills, solid programing, and respectful approach to patient care."
He noted that over the past year there have been many initiatives as part of the Retreat's ongoing performance improvement process, including the redesign of group programing; a focus on individualized treatment plans; the improved collection and analysis of data; and the streamlining of communication processes for staff.
"While this successful survey verifies our CMS certification, we continue to focus on ways to bring the best in quality care to our patients. We are currently seeking resources to renovate our adolescent inpatient program to enhance the environment for safety and therapeutic care."
Von Krusenstiern said this most recent CMS verification is significant news for the employees and clients of the Retreat.
"While surveys in the past have covered specific areas and activities, this survey reviewed all areas of the Retreat — top to bottom — and the survey team included not just reviewers from Vermont, but also five federal surveyors. And the survey found us to be in compliance with all of the CMS conditions of participation to provide mental health and addiction services."
The four-day review, from Nov. 16 to 19, was to review whether the Retreat's Systems Improvement Agreement has been effective. The SIA was instituted in October 2014 after the Retreat failed a survey conducted by the agency. The SIA, under which an outside consultant performed a full evaluation of the Retreat's systems, training policies and employee oversight, could be in effect for another year, but von Krusenstiern said he won't know if the agreement will be terminated until CMS' official report is released.
Since opening its 14-bed adult intensive unit as part of efforts to replace the Vermont State Hospital following Tropical Storm Irene in 2013, the Retreat had struggled to comply with federal safety rules, being cited by CMS on a number of occasions. If the Retreat had failed to adequately implement its SIA, it stood a good chance of losing federal funding.
In addition to CMS' surprise visit last week, the state's surveyors have visited the Retreat in response to activities, incidents and complaints, said von Krusenstiern. He said there have been no findings as a result of those visit.
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