By NANCY HICKS
/ Lincoln Journal Star
Tuesday, May 15, 2007 - 12:29:33 am CDT
The federal
government lifted the immediate jeopardy sanctions at the Beatrice State
Development Center Friday after the state made improvements to its system for
investigating complaints of client abuse and neglect.
The center made a number of changes in the abuse and neglect reporting system,
particularly in providing safeguards for clients during the course of an
investigation, said Larry Pezley, acting chief executive officer at the center,
which cares for about 340 people, primarily adults with serious developmental
disabilities.
As an example of the changes made, Pezley said, if two people have been involved
in a fight the center now has staff monitor them to make sure the two are not
able to contact each other during the followup investigation.
After a two-week inspection in late April, federal inspectors with the Centers
for Medicare and Medicaid Services (CMS) cited the center for failing to prevent
and detect abuse, neglect and mistreatment. That problem, if not immediately
corrected, would have meant an end to federal funding, which pays for about half
the $49 million annual cost of operating the center.
Administrators were apparently expecting a bad report from the federal
inspection team, based on an April 9 letter from Gov. Dave Heineman to Mike
Leavitt, secretary of the U.S. Department of Health and Human Services.
HHS leaders had “the overall impression that CMS has pre-determined that BSDC
will fail the upcoming re-survey,” based on a phone call and meetings, Heineman
wrote just before the Centers for Medicare and Medicaid Services inspection
began.
Apparently Centers for Medicare and Medicaid Services staff had asked Nebraska
leaders whether the state had made plans for the possibility that the federal
government would cancel its Medicaid contract with the state, according to a
copy of the letter obtained by the Lincoln Journal Star
Heineman wrote that there were “components of the phone call and meeting
conversations concerning what plans, if any, the state of Nebraska has for
receiving a notice of termination…”
HHS administrators would not respond directly to the governor’s letter. “We
continue to work closely with CMS to consider all options in order to meet the
federal requirements,” said the official response from Kathie Osterman, HHS
spokeswoman.
The April “immediate jeopardy” sanction was the second time in seven months that
Centers for Medicare and Medicaid Services found serious health and safety
problems at the center.
In September, the center received “immediate jeopardy” sanctions in three areas:
properly using interventions to manage inappropriate client behaviors; ensuring
clients are not subject to abuse or punishment; and developing and implementing
written polices to protect clients from abuse and neglect. Inspectors also found
the center deficient in seven of eight areas they monitor.
In April, inspectors found the center deficient in just two of the eight areas.
But they again pointed to serious problems with the center’s system to prevent
and detect abuse, neglect and mistreatment.
The inspectors listed four specific problem areas in the April report: The
center did not thoroughly investigate all allegations of unknown sources; the
center failed to ensure that sufficient safeguards were in place; the center
failed to take appropriate corrective action when a violation was verified; and
the center’s policy and procedures failed to recognize client-to-client abuse in
that they did not require specific levels of injury to be reported immediately
to the administrator.
Inspectors provided several examples for the “immediate jeopardy” citations,
drawn from their review of center investigations of incidents where clients were
injured.
These are a few of the incidents:
Staff did not visually check on a client every 30 minutes after putting him to bed during a shift change. The client was assaulted by another client during this period. Investigation staff did not view tapes of the incident until three or four days after the incident.
After a client choked on a teaspoon-size piece of hamburger, investigators determined that the kitchen had not been sending a sufficient number of pureed meals to the living unit. Staff had apparently not been reporting not receiving enough of the prescribed diets.
Client bumped his shin against a bedrail during the night. No one had considered padding the client’s bedrail.
Since the
center received its first immediate jeopardy citations in the spring, the center
has made numerous changes outlined in a report given to state senators last
month.
The changes include restructuring and beefing up the investigation unit,
improving an incident/injury review process, a massive retraining of all staff,
restructuring the center into smaller “neighborhoods,” reduction in the use of
physical and mechanical restraints, and a 6 percent reduction in the center
population.
The Beatrice center will now be responding to a report on less serious problems
from the April inspection, according to Pezley.
Reach Nancy Hicks at 473-7250 or
nhicks@journalstar.com.