RD365 - Office of the Inspector General for Behavioral Health and Developmental Services Semiannual Report April 1, 2010 – September 30, 2010


Executive Summary:
The Commonwealth’s system of behavioral health and developmental services has experienced both significant problems and opportunities in recent months, and the highlights of these are summarized below as required by § 37.2-424 and § 37.2-425 of The Code.

The Creating Opportunities Plan is likely the most consequential document created by the DBHDS in a generation. Commissioner Stewart and the State Board deserve accolades for the plan that will guide the Commonwealth’s behavioral health and developmental services initiatives for the next three and a half years – and beyond.

The Creating Opportunities Plan fashions strategic initiatives and action steps to realize the Department’s Strategic Plan vision of a community-focused system of care “that promotes self-determination, empowerment, recovery, resilience, health, and the highest possible level of participation by individuals receiving services in all aspects of community life.” With its focus on person-centered community-based services, achieving the highest level of independence – while engaging in meaningful activities and participating fully in the community, this impressive Plan holds-out the promise of achieving Governor McDonnell’s goal of creating a true Commonwealth of Opportunity for all Virginian’s – including those served by the Department of Behavioral Health and Developmental Services. We have appended a copy of The Creating Opportunities Plan to this SAR for convenient reference.

Following repeat site inspections during the spring and summer, the Federal Center for Medicare and Medicaid Services (CMS) decertified Eastern State Hospital’s (ESH) Hancock Geriatric Unit on September 12, 2010. Hancock Geriatric is a 150 bed geriatric facility on the campus of ESH in Williamsburg serving geriatric residents with a co-occurring behavioral health diagnosis.

The decertification means that ESH is ineligible to receive approximately $1.2 million monthly in Medicaid and Medicare payments until the Hancock Center is surveyed and deemed an acceptable provider to deliver services. The DBHDS and ESH are working to prepare for a re-inspection, but as of October 21, 2010, they had not scheduled a follow-up inspection from CMS to reinstate Hancock’s certification.

The Inspector General believes that Hancock’s residents are well cared for; nevertheless, all residents, and/or their legal guardians, were officially notified of the decertification, and given the option of relocating to another facility. The OIG understands that all residents chose to remain at ESH.

Since the fall of 2008, the United States Department of Justice (DOJ) has been actively investigating the Central Virginia Training Center (CVTC) and the Commonwealth’s system of care for persons with developmental disabilities. Under the current DOJ leadership, the investigation has expanded and evolved, from a review of CVTC’s compliance with the Civil Rights of Institutionalized Persons Act (CRIPA), into an examination of the state’s training center system, and an evaluation of Virginia’s community capacity measured against the requirements of the Americans with Disabilities Act (ADA) and the Supreme Court’s Olmstead Decision.

If the DOJ follows the model it created in Arkansas this year, Virginia can expect a Federal complaint alleging that the Commonwealth has failed to transition people confined to training centers to the most integrated setting appropriate to their needs, and that the state has inadequate community services to serve its developmentally disabled residents. These themes have undergirded DOJ’s Olmstead actions this summer against Arkansas, Georgia, New Jersey, Illinois, and Florida and are embedded in the Amicus Curiae brief DOJ filed in Federal Court in support of The Arc of Virginia v. Timothy M. Kaine, et al. (Civil Action No.: 3:09cv686). A summary of DOJ’s findings at CVTC can be found on page 25.

The tragic alleged patient-on-patient homicide earlier this year at CSH highlights the danger inherent in co-mingling patients with serious mental illness (SMI) with persons undergoing court-ordered evaluation who may have personality disorders like psychopathology. The forensic population is the fastest growing segment of Virginia’s behavioral health system and a top priority of the OIG for the upcoming year is to study this aspect of the system and recommend changes that will improve both patient and staff safety. Most forensic patients are admitted pursuant to a court order authorized by The Code including evaluation of competency to stand trial, restoration of competency to stand trial, emergency treatment prior to trial, or after, sentencing, various NGRI petitions, and TDOs & ECOs.

While overtime has been a systemic problem for several years in state facilities, this year overtime reached unprecedented levels at one state-operated facility. The OIG conducted an investigation of this facility’s use of overtime and concluded that, by any reasonable standard, its reliance on overtime was excessive. This facility’s unsustainable use of overtime, as opposed to employing a right-sized workforce, had a measureable and detrimental impact on resident care, employee retention and recruiting, and staff morale. The DBHDS has taken steps to correct the immediate problem at this facility and will presently issue clear instructions to establish overtime guidelines for the Commonwealth’s state-run facilities.