Fostering an environment of continuous improvement
Recent media reports have suggested that the staff of the Brattleboro Retreat have not been forthcoming about the contents of a letter, called a "notice of termination," received by the hospital from the federal Centers for Medicare and Medicaid Services on July 8.
My goals in writing this piece are to help readers better understand how federal oversight of healthcare facilities works, to assure the public that the Retreat has been completely open about its interactions with regulators and lawmakers, and to emphasize our staff's commitment to doing everything in its power to continue to meet and exceed all federal standards. Let me start with some background on the current situation.
In early May, an adolescent patient made a suicide attempt at the Retreat. As required by law, the incident was immediately reported to the Vermont Department of Mental Health. This triggered an automatic site survey (evaluation) by the Vermont Division of Licensing and Protection, which was conducted June 18 on behalf of CMS.
The survey found that the Retreat was not in compliance with three federal regulations. Two involved our environment of care; one concerned a nursing safety re-assessment. The environment of care issues involved one incident in which a key had broken in the lock of a door in a patient care area. The other involved a damaged ceiling light cover (that was subsequently replaced during the survey) in an elevator outside the inpatient units. Neither of the environment of care issues were related to the patient who made the suicide attempt.
The nursing assessment issue involved a nurse who did not complete a re-assessment of a change in patient health status reported by another member of the treatment team. The patient involved was the patient who made the suicide attempt. There was, however, a nursing assessment performed on the patient during the subsequent shift. That assessment was documented.
Around the time of the survey, we learned with deep sadness that the patient, who had been transferred to an out-of-state medical hospital, died approximately six weeks after the transfer. We learned of the patient death from public sources. Although we attempted to follow up with the other hospital, the patient's status was protected by privacy law and we were unable to obtain further information.
The surveyor's findings were accompanied by the aforementioned "notice of termination," which is a federal document stating that the hospital or healthcare facility in question must take action to return to full compliance with all federal regulations (in the Retreat's case, by Oct. 6) or risk losing its contract with CMS.
As daunting as this may sound, such letters are an automatic part of the notification process to healthcare providers who need to make operational improvements in order to meet the "conditions of participation" in a federal contract. That said, the Retreat certainly acknowledges the seriousness of the matter; and as with all CMS citations, we have developed a Plan of Correction that has already been approved by the Vermont Division of Licensing and Protection.
We are confident that when surveyors return on or before Oct. 6 to assess the effectiveness of our POC the Retreat will be back in compliance and its contract with CMS will continue uninterrupted.
Concurrently, and adhering to an agreement with the Department of Mental Health, the Retreat immediately provided copies of the CMS letter and report to DMH when it was received. The POC was also sent to DMH when it was accepted by CMS. As outlined in the agreement, DMH distributes copies of CMS reports to the chairs of the legislative committees of jurisdiction. It is our understanding that in this case, DMH provided copies of both the letter and the report to the chair and vice-chair of the Mental Health Oversight Committee.
The Retreat, at the request of the committee chair, also provided copies of its approved POC and accompanying findings to MHOC committee members through the committee's clerk and arranged to have clinical staff available to answer questions about the current situation with the committee at its July 22 meeting. At the MHOC meeting legislators asked questions about the POC, staffing at the hospital, and other issues.
Following that hearing, the Retreat has been criticized for a perceived failure to discuss the details of the CMS letter. Some charge that representatives from the Retreat should have raised the issue of the contents of the "notice of termination" letter at the MHOC meeting. Yet having already submitted these materials to the appropriate state officials, it is difficult to understand the outcry.
Any hospital or healthcare facility that is faced with the loss of federal funding is going to be highly motivated to make necessary corrections. The Retreat is no different. At the same time, we need to develop a more collective appreciation for the fact that, as part of the regulatory process, federal officials are required to issue uncompromising communications when working with healthcare providers to improve procedures and processes that impact patient safety.
Unfortunately, suicide is the third leading cause of death among adolescents in the general population, and suicide attempts occur at a much higher rate among adolescents receiving care in psychiatric facilities. Sadly, many of the adolescents who come to the Retreat for inpatient care have lost hope in their lives and are at risk to themselves.
The Retreat strives to do everything in its power to keep patients safe. We foster an environment of continuous improvement toward that end. We are confident that we are taking the appropriate steps to return to full compliance with federal regulations and that the continued funding of our federally supported patients will not be interrupted.
Konstantin von Krusenstiern is the vice president of Strategy and Development at the Brattleboro Retreat.
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