With $29 million in federal money on the line at Austin’s institution for people with disabilities, state leaders tried something they had never done in the center’s 97-year history: They hired a consultant to run the place.
The Columbus Organization took the reins of the Austin State Supported Living Center in May 2013. The center needed a big boost after yet another scathing report by state regulators that detailed problems they believed threatened the safety of the center’s 280 residents.
But after paying Columbus $1.2 million for its services over the past year, the Austin institution is facing just as many violations as it did before the consultants arrived.
Last month, state regulators cited the Austin center for failing to meet standards in five out of eight areas of patient care, the same number it failed during its last inspection in March 2013. In a 670-page report issued last month, inspectors said that one patient nearly died because of poor nursing care; another was choked, hit, scratched and otherwise attacked dozens of times by other residents; staffers routinely neglected to tell doctors about medication errors; and employees are working 16-hour shifts because of staff shortages.
The last member of the Columbus team left Austin in mid-March.
“I think it was a costly investment that did not produce the desired results,” said state Rep. Elliott Naishtat, D-Austin, who serves on the Texas House human services committee.
Columbus officials declined to comment.
Officials with the Department of Aging and Disability Services, which oversees the 13 state supported living centers in Texas, say they are satisfied with the company’s performance and that the consultants were never expected to solve all of the facility’s problems.
Commissioner Jon Weizenbaum said the center began to improve under Columbus’ leadership. Employees are now getting additional training and support, are working more closely with residents and getting more clients involved in activities outside of their homes, among other things, he said.
Independent monitors working with the U.S. Justice Department — which has ordered the state to overhaul operations at all the centers — recently praised improvements at the Austin facility, said Scott Schalchlin, assistant commissioner for the living centers. Monitors said last month that the facility is now in substantial compliance with 33 out of 161 requirements, up from 26 in November 2012.
“You never want to have a review that’s going to produce violations,” Weizenbaum said of the regulatory inspection. “But Columbus helped us do several very important things that we’re continuing to implement now.”
State regulators say that the living center has until June to fix ongoing issues that existed long before Columbus arrived last spring, medical care and client protections among them. If it doesn’t, the facility will lose its Medicaid certification, which brings the center $29 million annually, said Aging and Disability Services spokeswoman Cecilia Cavuto.
That do-or-die mandate is unlike other threats that regulators have made to the Austin center over the years, Cavuto said. Since January 2012, state regulators have threatened to decertify the center five times for failures in resident care. And each time, even when it didn’t make the necessary changes, the Austin facility kept its money through deadline extensions or special improvement agreements.
That’s not expected to happen this time, Cavuto said.
Texas’ living centers are state-run campuses for about 3,500 people with intellectual disabilities. Some residents live in a nursing home-style facility where they receive extensive medical care. Some live in houses with other residents, where they are to be supervised by staffers. Some residents have on-campus jobs, such as stuffing envelopes, or work at businesses in the community.
After an extensive investigation, in 2009 the Justice Department demanded changes to the way the centers care for residents, and the state agreed to scores of reforms. Independent monitors were hired to oversee those changes. Meanwhile, state regulators — whose work isn’t related to the Justice Department — continued to inspect living centers for violations of federal regulations.
Columbus was hired to run the Austin center in May 2013 when f ormer center Director Charles Bratcher was forced to resign. He was the third leader to have lost the center’s top job since 2010.
If state officials had chosen to stay with the status quo, they could have simply replaced Bratcher, who made about $95,000. Instead, they hired Columbus consultant Matt McCue and a team of seven consultants charged with figuring out what wasn’t working and developing strategies to fix the problems. McCue was also to handle the daily operations.
Columbus may have taken the reins in a time of transition, but its consultants were hardly newcomers to the living centers. Since 2009, the state has paid the company more than $5.6 million to provide consulting and training services to the state supported living centers. That includes the $1.2 million the Columbus team received for its work at the Austin center.
Despite that guidance — plus that of the Justice Department’s independent monitors — the center hasn’t been able to shake persistent problems. By giving the company more control, the state hoped to speed up the center’s recovery.
“I think it’s a continual process,” Weizenbaum said. “Any organization tries to continually look at where its gaps are and how to fix them.”
During McCue’s tenure, staff training increased 27 percent, Cavuto said. Injuries, which range from minor cuts to wounds that send people to the hospital, decreased 28 percent between January and February. Employees also meet regularly during “town halls,” participate in an employee advisory committee and are encouraged to offer suggestions to leaders.
A new Austin center director, Laura Cazabon-Braly, started in January. She is the center’s fourth leader since 2012. McCue stayed several months to help transition her into the job and left on March 14.
Another critical report
The Aging and Disability Services Department’s regulatory division annually inspects the living centers for federal regulations, which dictate the way such institutions must be run. Inspectors also respond to complaints about abuse or neglect at the centers.
In March, inspectors visited the Austin center for its annual review of the facility’s operations. In its report, inspectors documented:
- Lapses in medical care. One resident was supposed to have his fluids tracked for medical reasons, but “due to (the) facility’s failure to monitor, he was hospitalized due to seizures and almost died.” After the man returned to the living center, the staff still didn’t restrict his fluids, nor the fluids of 20 out of 24 residents who were also on such plans. Many residents, including the one who almost died, must have their fluids monitored because drinking too much can cause problems with their medications.
- Lack of meaningful treatment. Employees regularly failed to follow set plans to provide meaningful activities that make residents more independent, such as teaching them to brush their teeth, dress themselves, or cook.
- Medication errors. Staffers failed to ensure that drug errors for 120 out of 280 residents were all reported to their doctors. One patient didn’t receive the correct medication 21 times. When interviewed by the inspector, the nurse operating officer said that the process for handling such problems was being revamped and that the department hasn’t had any leadership for months.
Direct care employees blamed some of their problems on staffing problems. The center currently employs 453 direct care staffers and has 55 vacant jobs. About 8 percent of those 453 people call in every day. Meanwhile, 10-15 employees at any given time can’t work with residents because of pending investigations, Cavuto said.
Since May 2013, 10 staffers on the center’s leadership team — including the chief nurse executive and director of behavioral health services — have quit or been fired. And earlier this year, the facility had a spate of departures from its nursing staff when nine quit and one was firedbetween January and March.
Recruiting and keeping good staff is difficult because of the challenging work and competition for workers who could make more money elsewhere, Weizenbaum said. Maintaining stability at the living center is important, but sometimes change is necessary, he said.
“I want Austin State Supported Living Center to be a place that is known as one that’s turned around a difficult situation,” he said.
Inspectors also noted that staffers don’t have enough training. Throughout the report, inspectors repeatedly describe scenes of staffers trying to engage clients, helping them with puzzles, coloring with them or put their shoes on. Employees are noted trying to help residents stop spitting, rubbing their faces or slapping themselves. But when the residents won’t cooperate, staffers walk away to work with someone else, the report states.
• May 2010- March 2012
• Demoted, moved to another state job
• Salary as director: $90,000
Vira Benson arrived at the Austin living center in May 2010. At that time, the facility was in its second year of a $112 million agreement with the U.S. Justice Department to overhaul operations at the 13 living centers. Benson — who had held a variety of positions at state living centers since the 1990s — was expected to improve center services, such as medical treatment and nursing care.
But in March 2012, officials with the Department of Aging and Disability Services removed Benson after state regulators found serious safety, medical and treatment problems at the Austin center. The Justice Department also slammed the facility for failure to make progress, blaming the trouble on leadership and communication problems.
Benson was transferred to a job at the state office, where she works on living center compliance issues and earns about $73,000 per year. In addition to Benson’s removal, the Austin center’s assistant director of administration was demoted and the medical director retired.
“We believe that with new leadership in these roles, the facility’s ability to make substantive improvements will be significantly improved,” a state spokeswoman said at the time.
• June 2012 – May 2013
• Resigned in lieu of termination
• Salary as director: $95,000
When Charles Bratcher was hired in June 2012, the state living center was in trouble. Bratcher said he spearheaded major improvements to infrastructure issues, including water and gas problems. A January 2013 review by the Justice Department agreement monitors said the center was making much more progress than it had under Benson’s leadership.
But at the same time, state regulators found such serious problems at the center that it threatened to pull $29 million in federal funding from the facility. That’s when Aging and Disability Services told Bratcher to resign or he would be fired.
“We made the leadership change that we believe was needed to improve the health, safety and quality of life of all residents at the facility,” spokeswoman Cecilia Cavuto said. “We have not seen the substantive progress necessary to address these issues, and they are too important for us to delay taking action.”
Bratcher blamed the continuing problems at the center on crumbling infrastructure, staffing shortages, inadequate training and a lack of guidance from high-level state bureaucrats.
Matt McCue and Columbus Organization
• May 2013-January 2014
• Cost: $1.2 million, which funded McCue’s salary, plus that of seven other advisers
Matt McCue and his team were hired as consultants through the Columbus Organization, a private company that the state has used to help make the improvements required under its agreement with the Justice Department. Since 2009, the state has paid Columbus more than $5.6 million for its services.
State leaders said that McCue’s experience with the living centers would enable him to make the changes he could only suggest while working on the sidelines. His term was always intended to be temporary while the state looked for a permanent replacement for Bratcher.
Throughout his tenure, independent monitors of the federal agreement have noted improvements in active treatment services and have complimented the facility on the increase in programs available at the center, spokeswoman Cecilia Cavuto said.
McCue left the facility in March after helping new Director Laura Cazabon-Braly into the job.
“(McCue) and his team laid the groundwork for needed improvements, and now Ms. Braly is furthering implementation,” Cavuto said.
This month, state regulators slapped the center with a 670-page inspection report, failing the facility in five out of eight areas of patient care that make it eligible for Medicaid money — the same number of citations it received before McCue arrived.
• January 2014 - current
• Salary as director: $103,000
In January, Laura Cazabon-Braly became the Austin center’s third leader in seven months.
A soon as she arrived, the new director — who came to the facility after running the El Paso State Supported Living Center for about a year — was confronted with a January regulatory inspection faulting the center for continually failing to protect a resident from a violent client. And now, Cazabon-Braly is laboring to resolve health, safety and treatment violations identified by state regulators earlier this month.
State officials say they’re confident that Cazabon-Braly will get the institution on track.
Why it matters
Since 2012, the state has changed leadership at Austin State Supported Living Center four times as it addresses longstanding complaints about poor patient care, neglect and flawed treatment. While state officials tout improvements made to the facility, its staff and its policies and procedures, regulators are again threatening to freeze Medicaid funding, for the fifth time since 2012.