Retreat has 5 days to finalize corrections plan


BRATTLEBORO -- The Vermont Division of Licensing and Protection has found no violations occurred during an altercation at the Brattleboro Retreat between two patients that injured eight staff members in the Tyler 3 ward on July 20. Four of those staff members had to be treated for minor injuries at Brattleboro Memorial Hospital.

However, noted the report issued on Tuesday afternoon, during the investigation, which was conducted during a visit on Aug. 11, the DLP learned of an incident of inappropriate sexual contact between two adolescent patients, also in the Tyler 3 ward.

"As a result of the visit, the Retreat was found to be out of compliance on two CMS Conditions of Participation and two Standard level requirements," said Konstantin von Krusenstiern, the Retreat's vice president of strategy and development.

The Division of Licensing and Protection is tasked by the Centers for Medicare & Medicaid Services with conducting surveys and investigations of state facilities such as the Brattleboro Retreat.

According to the letter from DLP, which won't be available to the public until patient information is redacted by the Department of Mental Health, the Conditions of Participation citations were related to patient rights and quality assessment/performance improvement. However, von Krusenstiern shared with the Reformer non-confidential information related to the findings.

"The surveyors found that the hospital did not take the necessary steps to prevent the inappropriate contact between the two patients and did not adequately review the incident afterwards," he said.

According to the DLP letter, the Standard level citations were related to patient documentation and internal incident reporting. While staff had immediately reported the incident to the Vermont Department for Children & Families, and an internal investigation occurred, staff did not complete the required internal Retreat incident report paperwork.

According to CMS, hospitals must provide sufficient interventions to maintain care in a safe setting and maintain an effective quality assessment and improvement program.

The Retreat was already on notice from CMS following a June 18 survey, also conducted by the DLP, that was triggered when a teenager attempted suicide. That patient was subsequently transferred out of state and later died.

The June survey found inadequate follow-up to an incident in which a key broke in a lock in a patient area and a broken light fixture in an elevator that could have been used for self harm. Von Krusenstiern noted that the broken light fixture was located outside the inpatient units and was subsequently replaced during the survey.

According to von Krusenstiern, the Retreat has already submitted a Plan of Correction related to the June findings, which has been approved by the DLP. The Retreat must submit an amended plan including the latest findings to the Division of Licensing and Protection by Sept. 2.

"If we are not found to be in compliance by Oct. 6, then our CMS contract is terminated," he said. "However, we are confident that when surveyors return on or before Oct. 6 to assess the effectiveness of our Plan of Correction the Retreat will be back in compliance and its contract with CMS will continue uninterrupted."

According to CMS, there have been three suicides, at Retreat-managed programs in the past two-and-a-half years and two suicide attempts in inpatient care past four months.

The Retreat averages 3,000 inpatients a year, or more than 5,000 a year if you count those also in outpatient care.

Von Krusenstiern told the Reformer that the Retreat expects another survey prior to Oct. 6 to verify its is in compliance.

Bob Audette can be reached at, or at 802-254-2311, ext. 160. Follow Bob on Twitter @audette.reformer.


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