State improving but concerns remain about care for patients moving out of Gracewood

The state of Georgia is doing a better job of moving medically fragile developmentally disabled patients out of state hospitals such as the Gracewood wing of East Central Regional Hospital, a court-appointed observer said in a recent filing. But it is still not investigating and reporting deaths promptly when they occur, including one man who died just days after being moved from Gracewood, and it cannot follow its own procedures for reporting on and safeguarding those it deems at high risk of injury or death.


The state is also unlikely to meet its revised deadline of June 2018 for moving patients it considers in need of community placement, which the state contends is every patient at Gracewood currently.

As of March 1, there were less than 300 developmentally disabled patients still in state institutions, including 178 at Gracewood and 39 more in the rest of East Central Regional, independent reviewer Elizabeth Jones reported in her filing last month. Jones monitors and reports on the state’s compliance with a 2010 settlement agreement with the U.S. Department of Justice over conditions in state institutions that required the state to move patients to the most integrated setting for care. That settlement now includes an extension agreement from last May that includes revisions seeking to correct problems that cropped up under the original agreement.

Initial efforts to move hundreds of patients out into the community resulted in a number of deaths, and at one point the state agreed to pause placements to get a better handle on its discharge planning and increase the training of community providers. The renewed plan to begin placing patients in the community in the Augusta region, known as the Pioneer Project, has since been implemented statewide, and there are now 633 patients receiving “intensive support coordination” from support coordinators to better ensure they get proper care, Jones noted.

The Georgia Legislature gave the state Department of Behavioral Health and Developmental Disabilities $12 million to improve its community waiver programs to improve support, she reported, and the state is meeting its deadlines to provide certain waivers.

Despite this, there is a “very real likelihood” the state will not meet the revised deadline for moving patients into the community, Jones said.

Of the 26 community placements done between July 2015 and June 2016, there are success stories, including “A.S.,” a 25-year-old woman placed in a host home with a “middle-aged woman who shares many of her interests and preferences,” the report noted. The patient is friendly with neighbors and has made friends through church and has ceased her “maladaptive behaviors,” according to the report.

But the state is also not living up to providing crucial information on its own High Risk Surveillance List, a list revised monthly of patients who had transitioned from state hospitals to the community that the state deemed at high risk. The list often did not contain requiresd information, had inaccuracies or omissions, Jones found.

For instance, in February it notes that “J.W.” had an encounter with law enforcement and would need a review of his medications. “It was not reported that, in fact, there was a serious provider medication error and that J.W. did not receive his prescribed psychotropic medication,” the report stated. “As a result, he became unstable behaviorally.”

It was also not reported that the patient ended up in a crisis respite home and remained there, Jones noted. While those homes were designed for short-term stays, there were 19 patients who had been in them more than 30 days and one patient who had been in one since June 2013, the report found.

The state has pledged to do a better job of investigating and reporting critical incidents and deaths. One report was on a man, “N.J.” who died 17 days after being transitioned from Gracewood. The death was characterized as “sudden, unexpected and most likely unpreventable,” according to the report, although two staff members caring for him were cited in the report for failing to perform CPR before an ambulance got there, the independent reviewer noted.

She also found that nearly 40 percent of investigations were not completed within the required 30 days, although that seemed to happen most often when it was the providers who were conducting the investigation. The state has since assumed responsibility for investigations. The report also noted a number of deaths where a “corrective action plan” that could include remedial actions was not completed months after the death.

“Otherwise, any lessons learned through the investigation process will not be applied and the system of community supports will not be strengthened,” Jones noted.

The state welcomes the input from the independent reviewer, the behavioral health department’s press secretery, Angelyn Dionysatos, said in an email.

“We highly value the reflections and recommendations offered by the Independent Reviewer and her experts,” she wrote. “Their thoughtful work continues to inform the transformation of our service delivery system, which will position us to fulfill the obligations expressed in the Extension Agreement that was signed last May.”

However, with concerns about the pace of recruiting community providers to receive patients from Gracewood and other places, Jones wrote that “the current pace of placement will not enable such placement within the timeframe envisioned in the Extension.”

Families at Gracewood are lobbying to keep the place open. Although they have been told there is no certainty beyond 2018, they are still getting mixed messages from state officials and have heard the same talk for years, said Theresa Senior, whose daughter is at Gracewood.

“They’ve been giving us cutoff dates for years now and none of these things has come to fruition,” she said.


Reach Tom Corwin at (706) 823-3213 or

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Wed, 02/21/2018 - 21:34

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