Patient’s death at Eagle Eye Farm leads to state probe

Vermont AG William Sorrell. VTD/Josh Larkin

Vermont AG William Sorrell. VTD/Josh Larkin

At least two state agencies are investigating a small mental health treatment facility in East Burke where a patient turned up missing and was found dead several miles away on Jan. 5.

Both the Vermont Division of Licensing and Protection and the Vermont Attorney General’s Office confirm they are looking into Eagle Eye Farm and the circumstances surrounding the untimely death of Justin Ponzio.

Assistant Attorney General Linda Purdy said her office is probing whether there are possible Medicaid fraud issues involved at Eagle Eye Farm. Fran Keeler, assistant director of the division of licensing, said her office is looking into the circumstances surrounding Ponzio’s death under its jurisdiction as a licensing authority.

Ponzio, 31, was under the care of Eagle Eye Farm, a licensed “therapeutic residential facility” that treats “traumatic brain injured survivors as well as other ‘at-risk’ populations,” according to its website. Sarah Alexander, the current manager of Eagle Eye Farm, declined comment.

Ponzio wandered away from one of the buildings used by Eagle Eye Farm in the town of Westmore in the Northeast Kingdom the evening of Jan. 5. His body was found after a staffer called 911 to report him missing on the morning of Jan. 6, unclothed and lying in a fetal position in below-freezing temperatures a couple miles away, according to state police Sgt. Darren Annis of the Derby barracks.

The probe into Eagle Eye Farm comes as the state of Vermont has embarked on an ambitious shift in mental health care to a more community-based model of treatment following the closure of the 54-bed Vermont State Hospital in Waterbury by flooding after Tropical Storm Irene. The Legislature passed a bill authorizing the overhaul and it is expected to be signed by the governor this week.

A key issue in extensive legislative discussions on the new statute implementing the overhaul was assuring “the highest quality of care” in the new system through a broad array of reports and metrics, as well as creating an oversight system for patients under the “custody of the commissioner of mental health.”

VTDigger has learned that Eagle Eye Farm was cited for a number of serious deficiencies in two unannounced inspections by the Division of Licensing and Protection, which conducts inspections and oversight for the federal Medicaid program.

Ponzio is a former state hospital patient who had been under the state’s custody, but Mental Health Commissioner Patrick Flood said he didn’t know if he was under any continued state jurisdiction at the time of his death. His placement at Eagle Eye Farm was done privately, according to police.

The first inspection was conducted June 27, 2011, and found the facility had: no training for administration of medications in providing care to its clients; had not conducted background checks on three of four employees; had no treatment plans or discharge plans for two of its residents; had outdated and incomplete records on its patients; did not have clear criteria for eligibility of the people it was treating; and was providing custodial instead of therapeutic care.

A state official said the deficiencies at Eagle Eye Farm were not all technical or bureaucratic in nature, especially the ones involving medications.”

In addition, other record-keeping issues were identified related to medications and treatment, including missing records, as well as lack of training in fire drills.

The Eagle Eye Farm administrator at the time, Jennifer Whitmore, provided a detailed response and remedial actions the facility was taking, according to a July 22, 2011, letter by the licensing division.

The state subsequently reinspected the facility in an unannounced visit on Dec. 12, roughly a month before Ponzio died, and found that Eagle Eye Farm “failed to correct” some violations from the earlier visit. The deficiencies noted included failure to develop treatment plans for two of the three residents, and continued issues with records on the patients staying at the facility.

A remedial plan was submitted by the current administrator, Alexander, on Jan. 23, several weeks after Ponzio wandered away from his housing.

Larry Thompson, who was director of psychological services at the state hospital until he retired in 2008, said he has visited Eagle Eye Farm and felt the operation did a good job with patients such as Ponzio who came from the Vermont State Hospital in Waterbury.

“It has done very good work with some of our toughest clients,” he said.

At the same time, he said, state hospital staff who knew Ponzio “were pretty upset” about his death, based on comments he has read on Facebook regarding Ponzio’s care. He said that left him with “feelings torn in a couple of directions” about Ponzio’s care.

In emails to VTDigger, state hospital staffers questioned whether Ponzio’s placement at the farm was appropriate and whether he received a sufficient the level of supervision, as well as whether he should have been released from the state hospital.

Eagle Eye Farm was started in 1992 and in a 1995 Vermont Labor Board decision involving a medical reimbursement issue, it was described as being located on “100-plus acres of woodlands and pastures” with a large barn, large farmhouse and a converted house that is a residence for clients as well as staff.

Thompson said it was in a “very pretty area” in farm country and offered work programs along with therapy, and said he understood how appealing it could be to a family.

But the Vermont Labor Board decision also raised several issues about the training and capabilities of the staff in a ruling at that time that the facility was not qualified to receive state funds for care.

Keeler, of the licensing division, said the state generally conducts one inspection a year and when problems are noted the agency conducts a follow-up as it did with Eagle Eye Farm. As a result of the Ponzio case, she said “we may have an additional report forthcoming.”

According to Keeler, the state has 37 therapeutic community residences it oversees, which are defined as places that provide short-term individualized treatment to three or more residents with major life adjustment problems. A total of 15 registered nurse surveyors in her division check compliance with state regulations and to assure proper care is provided in a wide range of settings, from large nursing homes to assisted living facilities and residential homes. She called the staff “well trained” and noted they all must pass a national surveyor test.

Keeler said the deficiencies at Eagle Eye Farm were not all technical or bureaucratic in nature, especially the ones involving medications.

“That is significant for us,” she said.

While noting that he had not seen the deficiency reports, Thompson agreed that medication issues are important in any treatment.

Eagle Eye Farm’s website notes that its locale “enhances security relative to residents that may be at-risk for elopement.”

Ponzio’s medical history is confidential information and as a result several questions remain unanswered about the 1998 graduate of Oxbow High School. According to state police, he was housed in a separate facility located in Westmore away from the main farm at Eagle Eye but reports do not indicate if he had 24-hour supervision. Also unclear is whether he was in a locked facility when he walked away from his home.

The question of how he was housed is relevant because Ponzio has a record of elopement. He was involved in a dramatic incident at the Vermont State Hospital in August of 2007 in which he apparently walked away from the hospital and jumped out in front of cars on Interstate 89, nearly being hit several times. He was eventually rescued by state police but had to be subdued by being Tasered, according to a state police report.

Thompson noted that private facilities such as Eagle Eye Farm are unlike the state hospital in that they provide patients more freedom and access to the outdoors, which can present supervision problems. Even under tighter restrictions and strict supervision at the state hospital, he noted, the state hospital faced two suicides that occurred in 2003, which resulted in loss of the hospital’s federal certification.

Neither the attorney general’s office or the licensing division could say when their investigations will conclude or if any charges might be brought.

Andrew NemethyAndrew Nemethy

Comments

  1. Fran Levine :

    It is not surprising that there is risk involved when caring for individuals with a history of serious and persistent mental illness. We need to have a balance between safety and freedom for individuals who have a history of self harm or harm to others because they are mentally ill. That said, I knew Mr. Ponzio and I grieve his untimely death.

    I believe we need to re examine as a sociey how we choose to treat the most vulnerable of our citizens, including changing regulations that are administered by people who have no clinical expertise in treating the mentally ill. We also need to think about our involuntary medication treatment laws which currently are on hold for community implementation. And we need a place that is of adequate size and scope to provide care and society to those who are not able to tolerate this cold, cruel world without help. Vermont State Hospital was such a place.

  2. Curtis Sinclair :

    We need better community treatment programs. We do not need to go back to the old days when there were thousands of people locked away out of sight, out of mind in large psychiatric institutions.

  3. Pete Everett :

    Curtis, this is a Community setting place and not an institution. Funny how the Govenor and Commisioner tried to hide this and said there have been no catastrophies. Well this seems like one to myself and many others. There is a need for both not just Community based and this story shows exactly why. It’s also funny how it was hidden until after the new bill was signed, things are getting worse not better for mental health in Vermont since the flood. Why don’t the Commisioner and Govenor let Vermonter’s know the facts on the way the system is, instead of trying to hide things? People are not recieving the care they need and deserve since Irene and this is all levels of mental illness.

  4. Fran Levine :

    No one is saying we should “go back to the days when thousands of people were locked away”, though even that is a mischaracterization of the old system. Things have changed thanks to new treatments and an understading of mental illness. What I wonder: is it better to have people in crisis who are hallucinating and fearful sitting in an E.R. waiting days for a bed? Or dying like the three people who froze to death this winter? What we need is balance and rational care provided to those who can’t take care of themselves, not an ideological spin based on old resentments.

  5. We need a system of medical advocates who will be available to all in hospitals – especially the ER. These could be volunteers – not in the hospital chain of command. They could be important witnesses for those in nursing homes and other facilities.

    A medical advocate/witness is not the same as a medical contact person. The contact person is for the convenience of the hospital. An advocate is the person who is a witness for the patient. See my article titled HUMANIZE OR EUTHANIZE.

    This program does not have to cost a lot of money. It could be run by volunteers. The only qualification is compassion. Some people have family members who serve as an advocate. Others do not. I have been writing about this for years. One of my articles titled A DEATH ON VALENTINE STREET described the death of a man in Bennington.

  6. Curtis Sinclair :

    Every time something like this happens it’s the same cry against deinstitutionalization. Some would have larger facilities built and when another tragedy happened they would insist on even larger institutions until we were back in the old days with thousands of people locked away for their “protection.” Errors have been made in the implementation of deinstitutionalization. That does not make this basic human right a bad policy.

    neuro.psychiatryonline.org/data/Journals/PSS/3625/1116.pdf

    The U. S. Supreme Court ruled in the case Olmstead v. L.C. that unjustified institutional isolation of individuals with
    disabilities, including those with mental illness, is discrimination. In accordance with the Olmstead decision, any unnecessary institutionalization or isolation of individuals with mental illness must be eliminated.

    The Olmstead decision is in accordance with The Americans with Disabilities Act that is designed to halt all practices that segregate persons with disabilities. The ADA was a decision to reverse a legacy of segregation and degradation.

    Statement of Rep. Ron Dellums (D.- Calif.) during the final passage of the ADA in 1989 in the House of Representatives:

    “I have seen these institutions. The smell of human waste and detergent has stuck in my throat. I have looked into the vegetative eyes of its inmates in their sterile environments, I have heard of the premature death ratio and prevalence of pneumonia and necrotic decubitus, literally allowing them to rot in their beds, these living dead, our imprisoned Americans with disabilities.”

    http://www.accessiblesociety.org/topics/ada/olmsteadoverview.htm

    There is still too much abuse at psychiatric facilities. Hospitals failed to report to CMS 44 of 104 documented deaths related to restraint and seclusion between August 2, 1999, and December 31, 2004. (Department of Health and Human Services OFFICE OF INSPECTOR GENERAL September 2006)

    http://www.charlydmiller.com/LIB05/1998hartforddata.html

    http://psychiatricfraud.org/2010/09/man-died-in-restraints-at-colorado-state-psychiatric-hospital/

  7. Fran Levine :

    @ Ms Valentine: So where are these advocates in the current crisis? Even if there was a system of volunteers, it would be an incomplete solution to the crisis for reasons of liability, confidentiality and length of time required to treat a psychotic break.

    @ Mr. Sinclair: You are stuck in the past and fail to recognize the progress VSH in particular made in the past 5 years. The DOJ gave VSH high grades for improvement and dismissed the civil rights case they were pursuing. JCAHO gave VSH their highest grade and the sensory and other therapeutic interventions we initiated were having significant positive effects.

  8. Nicole LEBLANC :

    We dont need to go back to the dark days of institutionlization and segregation when people fall through the cracks in the community system. What we need to do is Spend more money on community based mental health services for people with developmental disabilties. Bigger isnt allways better?

  9. Curtis Sinclair :

    I am not the only one who realized how badly VSH was run. Here is an e-mail from someone who worked at VSH and had experience working in other hospitals. It is from an NPR broadcast. http://www.vpr.net/episode/48303/whats-next-for-vermont-state-hospital/

    Joyce-Marie:

    During your show this afternoon re: State Hospital I called in briefly to express my disappointment over the portrayal of the revoked certification of the State Hospital as being about no more than expired gravy in the refrigerator.

    Of the many institutions I have worked in during the last 40 years, never have I seen such devastating and disturbing lack of care for those in need than was evident to me on my first day working at VSH. There is much talk about the many and obvious shortcomings of the physical defects of the ancient and decrepit building. Much more pervasive, and to my mind, much more important is the profound lack of competence of the staff. Lack of credentials are one thing, but the serious, systemic problem is complete lack of initiative, compassion, incentive to learn and do better. On a daily, more accurately hourly basis, I witnessed “Professional” staff treat residents with well-intentioned incompetence (if they were lucky), more commonly intentional sarcasm, ridicule and verbal abuse. The nursing staff and psychiatric aide staff spend most of every day fighting openly and aggressively over turf. What few activities are available were led by individuals with no training, credentials or guidance on the topic they were leading.

    I feel very strongly that the main problem in providing care at VSH is not that “Well, these are, after all, the patients that cannot really get admitted anywhere else.” The truth is, patients at VSH are those with the misfortune to be both seriously mentally ill AND poor. Second, it is an enterprise that for almost 200 years has been allowed to lock the doors (to the collective sigh of the community) and operate just as they saw fit.

    These same staff members will not, I would say cannot, now come into the light of day and allow their manner of doing business to be subjected to the democratic, legislative investigative process. They will not change, they may possibly be unable to.

    VSH should not be recertified. Close it. This great state can and must do better for the most vulnerable among us, those with psychiatric disabilities. But in the meantime, shine every bloody available light on it and I will guarantee there is infinitely more to contest than the over -date gravy. The State “Hospital” is an absolute disgrace to this state and this great nation.

  10. Pete Everett :

    Curtis, I worked there as well during the time this email was written and have no clue who this person is. Anybody could send in a comment making things up. There was nobody by that name since 2007 who worked there, this would not be an easy name to forget. And once again this is something if in fact a real person, from 2 years ago, and they never stated when they worked there. This means their opinion could of been from 20 years ago. The community while yes needs to be better has already shown in just a few short months how it is failing. This is a community place that has failed 2 inspections in the last 2 years as well is under investagation by the State. How is this any better than VSH? It’s not. Like Fran said VSH had been recieving nothing but high grade from DOJ and got that certification back. CMS surveyors are hand picked by the Govenor and gee ole Jim wanted nothing more than to fail VSH, don’t believe the stories he would say everytime an inspection came up. CMS is part of the dirty politics that we see in this state and the country today.

  11. Trevor Chadwick :

    Everyone who feels like the state hospital isn’t needed has Justin’s death on them. Disagree with me all you want. There isn’t a system in place to handle the mentally ill. I have patients who died that I truly cared for once the untrained and unskilled community got their hands on them.

    I’m so sorry for Justin’s family that our Governor killed him by his inaction to do the right thing.

  12. Curtis Sinclair :

    I remember Justin. He was discharged WELL before VSH was flooded.

    It’s ridiculous to say that CMS had some kind of political agenda against VSH. The situation was so bad there that the staff became totally desensitized and unaware of how bad things were. Pointing out how bad Eagle Eye is does not make VSH any better. Now that more money and resources will be put into community programs there should be improvement.

  13. Pete Everett :

    If it is so ridiculous to say CMS had no political agenda, then why did the Department of Justice Which is a higher and more powerful body than CMS give Rave reviews in their past few assessments? If CMS was a fair body, then why does the Govenor have the right to hand pick the surveyors? Why did the Govenor put people in the surveying positions from APS who have always had an axe to grind. There has not been a fair CMS evaluation in numerous years. Trevor kudos to you! No matter how much money gets pumped into the community their will never be the equally trained staff that worked at VSH. Money going to opening group homes for Level 2-4 patients have nothing to do with Level 1 patient needs. There are not enough beds then or now to treat the number of Level 1 acute patients. As a matter of fact there are less now. Not only are there less now, but one of the facilities right now are turning away patients who are too acute or violent which is not suppose to be the case. The Govenor and Commisioner and the 3rd stooge ole Jeb were completely wrong in this new plan. People are suffering because of this and not getting the treatment they need. Community services can not treat Level 1 acute patients, and there is no arguement to prove otherwise.

  14. Curtis Sinclair :

    The Department of Justice investigates when facilities break the law. It is not a higher power than CMS. DOJ does not investigate all hospitals – only the WORST hospitals, the ones that have broken the law. The DOJ site lists only 18 state hospitals that have been invesitiagted. That makes VSH one of the worst 18 state hospitals in the US:

    From the special litigation section
    http://www.justice.gov/crt/about/spl/findsettle.php

    •Mississippi Mental Health and Developmental Disabilities Systems (12/22/2011)
    •New Hampshire Mental Health System (04/07/2011)
    •Delaware Psychiatric Center (Findings Letter) (11/9/2010)
    •State Psychiatric Hospitals in Georgia (12/08/2009)
    •Ancora Pyschiatric Hospital in Winslow, New Jersey (08/24/2009)
    •Kings County Hospital Center in New York, New York (01/15/2009)
    •Northwest Georgia Regional Hospital in Rome, Georgia (01/15/09)
    •Georgia Regional Hospital in Atlanta, Georgia (05/30/08)
    •Oregon State Hospital, Salem and Portland, Oregon (01/09/08)
    •Connecticut Valley Hospital, Middletown, Connecticut (8/06/07)
    •St. Elizabeths Hospital in Washington, D.C. (05/30/06)
    •Patton State Hospital in Patton, California (05/02/2006)
    •Alascadero State Hospital in Atascadero, California (05/02/2006)
    •Vermont State Hospital in Waterbury, Vermont (07/05/05)
    •Napa State Hospital in Napa, California (06/27/05)
    •North Carolina’s Public Mental Health Hospitals, Dorothea Dix Hospital in Raleigh, Broughton Hospital in Morganton, Cherry Hospital in Goldsboro, and John Umstead Hospital in Butner (03/17/04)
    •Metropolitan State Hospital, Norwalk, California (02/19/04)
    •Metropolitan State Hospital, Norwalk, California (05/13/03)

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