As Medicaid investigators threaten for the seventh time to freeze federal money to Austin’s institution for people with intellectual disabilities, officials say change is coming to the perennially troubled facility.
The state just hired the Austin State Supported Living Center’s fourth leader since 2010 to overhaul an institution where investigators say residents have suffered through substandard medical care, flawed treatment and serious neglect. Matt McCue’s expertise as a national consultant on improving institutions will bring a fresh eye to the persistent problems, officials say.
But Charles Bratcher — the last administrator brought in to clean house — said the facility’s new leader is likely to face the same quagmire he did: crumbling infrastructure, staffing shortages, inadequate training and a lack of guidance from high-level state bureaucrats.
Whether McCue gets the time and support he’ll need remains to be seen. Bratcher was on the job for barely a year when he was forced to quit.
“I was told I’d be around regardless of what happened, even in the event of loss of (Medicaid) certification,” Bratcher said in an interview with the American-Statesman. “Obviously, that didn’t happen once the pressure was on and someone had to take a fall.”
Officials with the Department of Aging and Disability Services, which oversees the state living centers, say they are trying to make the 300-bed center better.
“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.”
The clock is ticking for Austin to gain ground. All 13 living centers are bound by a 2009 agreement between the state and the U.S. Department of Justice to overhaul conditions at the facilities. Independent monitors are expected to file a comprehensive report on the state’s progress by June 2014.
But efforts to fix the problems have been hindered by conflicting assessments of what is happening at the center, Bratcher said. While the Justice Department was recently praising his work, state investigators who look out for abuse slammed the center for poor care. Meanwhile, administrators at Aging and Disability Services had their own take on what was going on, Bratcher said.
“There is no clearinghouse to make sure all the regulations are consistent and administered fairly,” he said, adding that his bosses were part of the problem. “State office doesn’t have a clue. They want to monitor the facilities to tell them what they think is wrong, rather than seek solutions and common ground.”
Raising the stakes
The state-supported living centers care for about 3,600 people with intellectual disabilities, such as autism and cerebral palsy. In its agreement with the Justice Department, the state agreed to make sweeping changes to medical, psychiatric and nursing care and other services at all of the facilities.
It’s not easy for an outsider to decipher exactly how much progress is being made. Some monitoring reports are more than 400 pages long and include dozens of requirements to be met.
None of the centers is in full compliance with the agreement, but monitors never expected that. In their progress reports to the state, they regularly say they believe the most significant changes will come this year.
Since 2009, the state has spent more than $100 million to hire 1,100 new employees, install security cameras, fix up old buildings and buy new equipment for patients. It has moved about 1,100 people out of the institutions and into smaller, community-based homes.
Cavuto said the centers, with a combined budget of $560 million, are making steady progress. But state investigators who examine complaints at all of the living centers continue to find serious problems. Over the past four years, they have threatened more than 50 times to halt the centers’ Medicaid money unless deficiencies were corrected.
Austin is under such a threat for the seventh time in four years.
According to one report, in February a resident died in a recliner as staff members ignored his worsening medical condition, another suffered severe burns when staffers bathed him, and a third was seriously hurt when his roommate attacked him after repeated confrontations.
The center has until June 17 to resolve the problems with patient care or it could lose $29 million a year, more than half of its annual budget.
Other efforts to transform the facility are in the works. All frontline workers are slated for 10 percent raises, Cavuto said. About $4 million in construction work is scheduled on the nearly century-old campus.
A revolving door
Austin’s frequent leadership changes might factor in to the ongoing problems.
When the Justice Department agreement was signed, the facility was run by longtime state employee David Ptomey. In March 2010, Ptomey resigned after being accused of favoritism in the workplace. He was replaced by Vira Benson.
In March 2012, Benson was removed after state officials said she had not done enough to fix problems at the center.
Bratcher — who worked for 36 years in state facilities for people with developmental disabilities — arrived in April 2012. Monitors had just blasted the center for its lack of progress. State investigators were threatening to withhold the federal money because residents were running away, hurting people, threatening to kill themselves, being restrained too often and sitting around with nothing to do.
Bratcher said he was “instructed to fix everything I could.”
“When I took the director position, I didn’t realize the mountain that was left to climb,” he said.
Bratcher said he and his staff quickly tried to improve treatment and activities for the residents. They increased vocational programs, reopened the campus pool and canteen, and started programs in areas such as music therapy, horticulture, and arts and crafts. He said the staff ordered new furniture, medical equipment and clothes for residents, sold broken vehicles and bought new ones. Court-approved monitors who returned that November praised the facility for the changes.
“The findings from this most recent review were very different, and much more positive,” their report reads.
At the same time, state investigators were documenting the problems with patient care.
Bratcher said part of the problem is that employees don’t get consistent training on how to deal with an aging and medically fragile population. Employees regularly call in sick or fail to show up. Those accused of abuse or neglect must be reassigned to jobs away from residents until the allegations are resolved, leaving people with fewer caretakers.
That forces other staffers to work double shifts, and sometimes they have to serve clients they don’t know well, and that can lead to problems, Bratcher said.
Still, Austin has drastically slashed its annual turnover rate for direct care staffers. In 2009, it was 69 percent. Now it is 34 percent.
The turnover has dropped in part because of higher salaries, Cavuto said. Thanks to previous raises approved by legislators, direct care staffers — employees who help residents with their daily activities such as eating and showering — make anywhere from $24,000 to $31,000 per year. This year, legislators approved a 10 percent salary increase for all such employees at the 13 institutions.
Nevertheless, it’s hard to find quality employees willing to do such a difficult job, Bratcher said.
“The staff care about the residents, often more than they are given credit for, but when you can make the same money at Dairy Queen and not have to put up with the constant pressure and hammering the staff got put through, why would you stay?” he said.
Staff told to shape up
Infrastructure problems also continue to plague the center, Bratcher said.
Last year, the facility spent about $3 million to repair its gas and water lines, Bratcher said. Older buildings are in such bad shape that 10 have been abandoned and boarded up. State officials say those buildings are full of asbestos and too costly to rehabilitate.
Some of the on-campus cottages, small homes that house roughly a dozen residents, are also falling apart, Bratcher said.
“On the smaller living cottages, they have not been improved since they were built in the early ’70s, and we found walls literally rotted away that have yet to be completely replaced,” he said.
Cavuto said several buildings are receiving new roofs, including the chapel and the canteen. Another 22 homes and buildings on campus will get new roofs in the coming months. Additionally, a project to increase the water pressure across campus is almost finished.
Bratcher said he always knew that significantly improving the center was more than a one-year job. At first, he said, he received ample support from state officials who controlled the resources, information and money he received. But when a key administrator left, that support began to dry up, he said.
He said he was not given specific time frames in which to accomplish goals and never received formal feedback, such as a personnel review. Cavuto agreed that there was no review but said Bratcher was given a performance plan that outlined goals and expectations.
On May 15, an obviously frustrated Bratcher — who was dealing with the threat of losing Medicaid money — sent an email to all 1,100 living center employees. The institution was “under the gun,” he wrote, and its survival depended on its employees’ actions.
“You will have a professional, cordial, and responsive attitude in the future with the surveyors and anyone else on this campus or you will find yourself without a job,” Bratcher wrote. “You will provide continuous active treatment, immediate and responsible care, competent professional services and reviews, and an overall positive impact, or you will need to find other employment because we will provide this without fail. This will be the new normal for us.”
Two days later, Aging and Disability Services officials told Bratcher to resign in lieu of termination.
“It takes a team of people working together to operate the (living centers) and to make the necessary improvements,” Cavuto told the American-Statesman. “That cannot be accomplished if staff members feel they are being held accountable for all challenges without the support of facility leadership.”
Bratcher said he had no idea he was about to get fired. Just two weeks earlier, he said, officials had given him some “very nice feedback” on his work at the center. Bratcher said the only reason he was given for being ousted was that administrators wanted to make a change.
Although the Austin institution has been through multiple directors, Cavuto said this time is different because the new leader comes from outside the state system, has worked with similar facilities around the country and can bring new solutions to the table.
Andrea Ball has covered social services for the American-Statesman since 2002. Recently her work prompted a federal investigation that concluded poor health care killed a patient at Terrell State Hospital. She has also reported about sluggish efforts to find affordable housing for homeless people and complaints about adult guardianship services in Texas.