The Georgia Department of Behavioral Health and Developmental Disabilities still has not put a good system in place to support developmentally disabled patients moved from state facilities into community care, and it’s unclear if it is following recommendations to better investigate patient deaths, an independent monitor said.
While the state is doing better to meet recommendations on improving care for mental health patients in community settings such as group homes, it is unlikely to meet its July 1 deadline to achieve all of its obligations under the Settlement Agreement with the U.S. Department of Justice, Independent Reviewer Elizabeth Jones said in her latest court filing.
Georgia entered into the agreement with Justice in 2010 after the state was found not meeting its obligations under the Olmstead decision to provide care for mental health and developmentally disabled patients in the most “integrative” setting. As part of that agreement, the state agreed to provide greater community supports for thousands of behavioral health patients and to begin moving 150 developmentally disabled patients each year from state institutions to community care.
Those transfers were halted in 2013 after a number of those patients died and Jones determined the state was not meeting their needs. She subsequently found the state non-compliant for support services in reports in March last year and the state came up with a plan to begin a new system of transfers for patients in the region that includes Augusta under what it termed its “Pioneer Project.”
However, in her latest review filed last week, Jones noted that only two women have been transferred from the Gracewood wing of East Central Regional Hospital under that program into community care; although Jones noted that 18 are slated for community placement “in the near future,” including five from Gracewood and four mental health patients from East Central.
The two Pioneer placements are not enough evidence to judge whether the state has created a better community support system, she said, but they “appear to be solid. Both individuals were transitioned carefully into their new home; residential staff was trained in their needs for support prior to the placements, and the monitoring by the Regional Office has been timely.”
Jones also noted an effort to integrate the patients into their neighborhoods and create opportunities for interaction with the community. She had previously criticized state efforts to meet those needs but praised recent guidelines for “early engagement” of community providers with patients and caregivers prior to the patient transfer.
However, there are still questions about how the state is ensuring patient safety and reviewing deaths, a problem Jones ran into when she tried to get records on one of the developmentally disabled patients she and her consultants visited as part of their review. She could not obtain a complete set of records because the agency responsible for the care had closed without giving the state those records, according to the filing.
“This problem is of serious concern,” Jones wrote, in that it prevented her from “determining the extent to which this individual had been put at risk in his community placements.”
As part of its reforms and at Jones’ recommendation, the state also hired an agency to do independent reviews of deaths, including those transferred under the settlement agreement who died. As of January, there were 499 patients transferred and 62 deaths, according to the department.
An investigation by The Augusta Chronicle uncovered 500 community care deaths in 2013, including 82 classified as unexpected, and 498 in 2014, with 141 unexpected. Jones met with the department in February to discuss the reports and raised a number of questions.
She is “reviewing whether the Department has taken any of the remedial actions recommended” in those reports. That includes “repeated recommendations” that the state get medical records on deaths and “ensure that autopsies are performed in a timely manner,” Jones wrote. That appeared to be a widespread problem in 2013.
Of the 28 developmentally disabled unexpected deaths reviewed in the newspaper’s investigation, only three had autopsies, even though state policy requires the provider to request one in an unexpected death.
In the case of both 12-year-old Christen Gordon and 18-year-old Cornelius Evans, who will be featured Sunday in the second part of The Chronicle’s investigation, both mothers said they requested autopsies but were denied.
In light of these problems and the need for more time to implement reforms, Jones said it is unlikely the state will meet the July 1 deadline and that the state and Justice should seek to get an extension.