Hancock Geriatric Treatment Center (HGTC) is part of the campus of Eastern State Hospital (ESH), located in Williamsburg, Virginia. ESH is a state operated facility, exempt from state hospital licensure by Virginia statute. In addition to the geriatric units within HGTC, ESH also provides acute psychiatric inpatient services for adults, including both civil and forensic commitments.

HGTC sought and was awarded Medicaid certification as a nursing facility, effective January 1, 1973. From 1973 to 2008, HGTC was surveyed annually, and retained certification through those years. HGTC received occasional citations during these years, as is common for most nursing facilities, with issues about documentation and staffing, but was able to mitigate the citations through corrective action plans, and remained certified.

In 2010, HGTC was surveyed by the Centers for Medicare and Medicaid Services (CMS) state contractor, and found in non-compliance for serious deficits in quality of care. HGTC was notified by CMS on August 25, 2010 that the facility was terminated from the nursing facility program and no longer eligible for Medicaid reimbursement, and Medicaid certification was withdrawn effective September 12, 2010. HGTC subsequently attempted to achieve recertification, completing a corrective action plan addressing the deficiencies cited in the 2010 surveys, and requested another survey in 2011. On March 28, 2011, CMS notified HGTC that the facility was reinstated as eligible for Medicaid reimbursement effective March 14, 2011. From 2011 to 2014, HGTC was surveyed multiple times and successfully maintain certification, with no indication of serious issues regarding the continuation of Medicaid certification.

In February 2015, HGTC was again surveyed. As a result of the 2015 survey, HGTC received written notification from CMS that HGTC did not meet the definition of a nursing facility. This included the finding that HGTC was an institution for mental disease (IMD) and, as such, is prohibited from being certified as a nursing facility. The Department of Behavioral Health and Developmental Services (DBHDS), in part based on advice from attorneys, determined not to pursue remediation via a plan of correction, or informal dispute resolution. A determination was made that the nursing facility Conditions of Participation (CoP) are not compatible with the HGTC’s model of care, and HGTC would not be able to reach and maintain compliance with the federal certification requirements. CMS decertified HGTC on August 26, 2015.

In March of 2017, DBHDS engaged Behavioral Health Policy Collaborative, LLC (BHPC) to develop a report that included certification options and a recommendation for whether to seek Medicaid nursing facility certification of all or a portion of the HGTC at ESH. BHPC engaged Health Management Associates (HMA), and Olshesky Design Group, LLC (ODG) as partners in the endeavor.

In developing the report, the team reviewed relevant state and federal regulations, obtained documentation from HGTC’s certification surveys and completed interviews with key informants regarding the 2015 survey and subsequent decision making. The team also completed an on-site clinical services review, and an on-site facility condition assessment. The team’s findings and observations from completing these activities are summarized below and addressed more fully throughout the report.

At the time of the 2015 decertification of HGTC as a nursing facility, the citations appear to have been valid. Interviews with staff confirmed that the restrictions observed and documented in the survey findings were in place at the time of the survey and had been for prior surveys. This includes that HGTC was operating as an IMD during prior survey periods, even though that had never been cited as a barrier to certification by the state survey agency.

The on-site assessment of the current operation of HGTC was conducted to assess both the needs of current residents and to identify what changes would be needed to achieve recertification as a nursing facility. The BHPC Team’s review was of 2017 clinical services and a sample of current patients. The HGTC patient population in 2017 includes individuals whose clinical and other service needs are not appropriate to be served by a nursing facility. Such patients include those who require some type of psychiatric stabilization or active treatment for serious mental illness (SMI). For the health and safety of patients and staff, it would be difficult if not impossible to provide these patients with the range of choices and freedoms expected by the nursing facility certification requirements.

Since the 2015 HGTC certification, CMS issued new federal requirements for nursing facility certification. The emphasis of the revisions is primarily around issues of resident independence, self-determination, privacy, and choice, all issues that HGTC was cited for when certification was terminated. And, issues that likely remain as barriers today if nursing home recertification is sought.

During this time period and to date, Commonwealth of Virginia statutory changes significantly increased demand for state psychiatric hospital beds. Virginia law now provides that state-operated hospitals cannot refuse the admission of a person held under an Emergency Custody Order (ECO) following a Temporary Detention Order (TDO) evaluation when an alternative facility cannot be found and the ECO eight-hour period is expiring. There are no exceptions to this requirement.

Because of the nursing facility decertification, the residents in HGTC lost access to Medicaid reimbursement for their care, which shifted the full cost of providing services to the Commonwealth. At the same time, the new statutory and regulatory pressures on the state operated hospitals in Virginia resulted in a rapid increase in admissions at HGTC and elsewhere. The increased demand for beds, coupled with the fact that HGTC was no longer a certified nursing facility, resulted in HGTC beds being used for general psychiatric admissions for older adults. HGTC’s role of accepting statewide referrals for geriatric patients needing nursing facility level of care shifted to a largely regional role.

The shift in population demanded an increased focus on acute stabilization to meet the treatment needs of individuals admitted to those beds. This focus has implications for the model of care and staffing needs at HGTC. This shift combined with a high demand for beds has led to admission practices wherein a TDO often determines priority for admissions and placement rather than the clinical need or current medical, cognitive and psychiatric functioning, and a strain on staffing trying to meet the needs of varying levels and types of needs of patients on a single unit that can result in some patients not receiving individualized and appropriate care.

While the HGTC facility condition assessment conducted by our team did identify some deficiencies (areas requiring remediation), the building itself is relatively new, built in 2008, and is in generally good or excellent condition. BHPC’s Team also assessed the Kitchen and Dining Facility, Building 13 of ESH, which was built in 1954. The latter building was included in the assessment because it is mission critical to providing services to HGTC patients regardless of certification status and funding source. The Superstructure and Substructure of Building 13 were built to last well beyond 100 years and are in good condition, however, the systems in the building are designed for a shorter life span. Some systems in the facility (i.e., the sanitary waste piping, drainage for boilers, air handling units) need immediate attention and are critical to maintaining the mission of HGTC.

Relative to nursing facility certification, the issue of whether HGTC is an IMD seems the most challenging to overcome. The HGTC characteristics that identify it as an IMD are not ones easily subject to change including: being under the jurisdiction of the state’s mental health authority, being maintained primarily for the care and treatment of individuals with mental diseases, and having more than 50% of all patients admitted based on a need for institutionalization as a result of mental disease. Admission requirements to HGTC require an individual to have a psychiatric diagnosis, which on its face argues that the facility meets the federal definition of an IMD.

Based on these findings, the BHPC Team’s recommendation is that HGTC not seek to recertify as a nursing facility and rather, increase its focus on: providing acute stabilization for older adults with psychiatric symptoms; assessment and evaluation of complex cases that require an interdisciplinary team made up of psychiatric, medical and neurological specialists to discern individual conditions and provide differential diagnosis and recommendations for placement (e.g., inpatient psychiatric care verses community based long-term care); treatment of individuals with serious mental illness (SMI) who are aging and have intractable or poorly controlled psychiatric symptoms and subsequent behavioral challenges, including older adults with forensic commitments.

There are numerous reasons that the BHPC Team does not recommend HGTC recertification as a nursing facility. In addition to the IMD issue, there are important competing demands for the 80 beds located at HGTC. Following the changes to admission requirements for State facilities, many of these 80 beds are now needed for individuals with acute psychiatric needs whose admission was not based on the need for long-term nursing facility services. Second, even if HGTC could seek to establish a dedicated unit to certify as a nursing facility to support older adults in the Commonwealth who need long-term care, it would take a significant effort to bring HGTC up to the standards for certification—particularly the new Federal requirements. This would take financial and other investment and require significant changes to the model of nursing care at the facility when it was operating as a nursing facility. These efforts include relocating patients currently at HGTC who do not have a nursing facility level of care, and the challenge of meeting the updated certification requirements for nursing facilities that are even more focused on individual freedoms and choice than the requirements that were in place at the time of decertification.

In addition, BHPC’s Team recommends that DBHDS, ESH, and HGTC explore options for developing the capacity for long term services and supports (LTSS) outside of the state hospital system for HGTC patients who need nursing facility level of care, whether they have a stabilized primary psychiatric conditions or neurocognitive disorders with behavioral issues. DBHDS can focus efforts on developing community based LTSS options that would allow individuals to receive community based care and reside outside of a nursing facility and could develop strategies to support private nursing facilities to successfully admit and care for individuals who no longer need the psychiatric acute care offered at ESH. This might include working with a private operator(s) to develop nursing facility capacity with a model of care and operating protocols that satisfy nursing facility requirements while also being properly staffed to handle difficult to place populations (including geriatric patients with a psychiatric history or current behavioral challenges).

Under a separate effort from this report, DBHDS engaged HMA to create a Virginia Geropsychiatric System of Care Report that will present a comprehensive plan for the publicly funded geropsychiatric system of care in Virginia. The report will identify the appropriate array of community services including the costs and revenues for each option. The options and recommendations in the forthcoming report will further detail options for the development of community based LTSS.