State inspectors will have to approve a planned “psychiatric residential treatment” program for adolescents at the Brattleboro Retreat before it can begin operations.

Rep. Anne Donahue drafted a successful amendment to the legislature’s annual appropriations bill this spring to impose a licensure requirement upon the 15-bed project, which had seemed poised to enjoy unusually little scrutiny prior to opening. Another bill subsequently added patient protections and more detailed rules for oversight.

Because Medicaid will pay for services at the facility, it will have to demonstrate compliance with federal standards. Vermont’s hospitals and therapeutic residences must also acquire certification on the state level, but thanks to a regulatory blind spot, the proposed facility in Brattleboro appeared likely to fly under the radar before Donahue’s intervention.

“The Agency of Human Services kept saying this does not need to be licensed by the state,” Donahue, a psychiatric survivor, told the House Committee on Appropriations. “It wasn’t clear why it wouldn’t need to be licensed, and questions were asked and answers had not come back.”

Donahue recounted turning to Vermont’s Division of Licensing and Protection for answers. In her telling, DLP responded that because no one in Vermont had ever sought to establish what the Centers for Medicare & Medicaid Services call a “PRTF” (or “psychiatric residential treatment facility”), state legislators had never written a law to demand the licensure of such a thing or standards for licensing it.

Ironically, last year, the Retreat asked for an exemption from an obligation to apply to the Green Mountain Care Board for a Certificate of Need on the basis that its planned PRTF was not a new program but merely a resurrection of an old, briefly dormant outpatient operation. The Retreat’s plan had arisen from a request for proposals issued by the Vermont Department for Children and Families, which, however, described a PRTF as a provider of “inpatient psychiatric services” with the power to use restraint and seclusion, not as an outpatient residence.

The Care Board, which must approve prospective healthcare projects in Vermont before they can break ground, accepted the Retreat’s reasoning and declined to assert jurisdiction, but it will review the question again following an update on the project that arrived in late April. A letter from the Retreat argued that a Certificate of Need remained unnecessary, but it now acknowledged some differences between its earlier form of residential treatment and the program currently in the works.

“It is important to note that the Brattleboro Retreat does not intend to rigidly replicate the treatment that it provided in 2020, but rather has designed a program that will better meet the needs of today’s adolescents,” the hospital’s lawyer wrote.

Irrespective of the Care Board’s final decision, the Retreat will now have to file an application with the Vermont Department of Health before its PRTF can open. The State Board of Education will license its educational component. When using emergency involuntary procedures, such as forced drugging, the PRTF will have to follow the same protocol as a hospital, which must always provide a written justification to Vermont’s Mental Health Ombudsman.

Legislation posited that these safeguards would ensure that the PRTF “complies fully with standards for health, safety, and sanitation” while upholding “person-centered care and resident dignity.” By Donahue’s account, the executive branch came around to seeing licensure as a good idea, too, even before it became law.

“Both the Department of Vermont Health Access and the Department of Mental Health have sent emails back saying they are completely fine,” she said. “It is their intent to get licensing now.”

Even so, the legislature decided – apparently with state officials’ blessing – to get it in writing. They also clarified that a PRTF would, in state law, constitute a form of inpatient care. In February, Commissioner of Mental Health Emily Hawes had labeled it as “an outpatient service” in legislative testimony.

“But it’s also not one-time-a-week therapy,” Hawes acknowledged at the time. “It’s residential, where folks are staying anywhere from three to 18 months and getting that intense family work that folks need in order to step back down into their communities.”

The Retreat’s Linden Lodge, a historic building where physicians also provide hospital-level care, will house the program.

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