‘It’s bad:’ Report on behavioral health facilities details abuse, neglect


CHARLESTON — A young man who drank antifreeze and was left for 12 hours before receiving medical care. A child who died in a “fiery crash” after finding the keys to a facility car. A woman restrained by having her shirtsleeves tied behind her back 24 hours a day, except to shower. Staff refusing CPR, resulting in death. No staff training except after a client died. 

These are just a few of the stories reported in an eight-page report on behavioral health facilities in West Virginia presented to the Legislative Oversight Committee on Health and Human Resource Committee meeting Monday morning. The report details complaints over the past two to three years. 

Del. Matt Rohrbach, R-Cabell, said it was the worst report he has seen in his seven years in the Legislature.

“There are some good providers but overshadowed by many critical systematic issues we find in facilities. It’s a growing trend and it’s bad,” said Jolynn Marra, director of the Office of Health Facility Licensure and Certification within the Department of Health and Human Resources. 

Behavioral health centers in the state provide a continuum of services for the treatment of individuals at-risk of or suffering from mental, behavioral or addictive disorders. There three kinds of behavioral health providers: group homes, which includes intermediate care facilities for individuals with intellectual disabilities (ICF/IID), and residential units; outpatient services, including day programs; and substance use disorder facilities providing behavioral health services.

There are 611 licensed behavioral health sites in West Virginia, not including IDD waiver homes with three or fewer individuals. Of those, 228 are residential group homes.

Top complaints from all behavioral health centers in 2020 were abuse and neglect by staff, violation of rights and safety concerns. 

Intermediate care facilities and homes with more than three people are more carefully inspected than the waiver homes, Marra said. Unlike waiver homes, the licensed homes require health inspections and fire marshal inspections and must be Americans with Disabilities Act compliant. The federal Centers for Medicaid and Medicare inspect the residences and also provide oversight.

But waiver homes are only inspected when there is a complaint.

The list of incidents does not differentiate between the facilities, showing the issues are pervasive throughout the system. In several instances, the neglect by staff led to death.

A consumer in Cabell County was not provided a shower for months, only periodic “sink baths.” Her hygiene was so bad the staff took it upon themselves to give her a “tight military hair cut to irradiate the problem of matted hair and odor.” The person just needed a shower chair.

Also in Cabell County, a consumer sustained a fractured nose of unknown origin and the provider neglected to follow its abuse and neglect policy to protect the consumer pending the outcome of an investigation.

Cabell County was where a consumer died, prompting staff training. A consumer died in a Cabell County facility after she choked on food contrary to her diet orders. Management tried to conceal culpability by lying to first responders, hospital staff and state regulators saying the patient choked on crayons. 

Rohrbach said he was angry following the committee.

“Is the state still doing business with operators that allow this to occur?” he asked Marra. The answer is yes. 

Marra said closing facilities down just exacerbates the problem because once beds are gone, they are gone. 

“We’ve done bans on admissions; we’ve lowered bed counts,” Marra said. “But we don’t close because we work to improve them because of the placement need. I know it’s a Catch-22. When we close an ICF, those beds are gone. Instead of closing, we visit more.”

Marra said there is a workforce issue, both in finding qualified professionals to assist these individuals and within her office. There are nine surveyors for behavioral health within OHFLAC and three vacancies. 

Beginning June 1, OHFLAC will be able to assess civil money penalties against facilities that fail to come into compliance. State code will also be updated relating to patient rights, care and safety. And DHHR continues to work to get facilities into compliance. 

“The individuals need a safe place to live,” Marra said, “the key word being safe.”

Marra said they make constant referrals to law enforcement and work closely with Adult Protective Services, and they will continue to be diligent. But Marra said there needs to be a review with all stakeholders on how to fix the pervasive problems within this system.

Reporter Taylor Stuck can be reached at tstuck@hdmediallc.com. Follow her on Twitter and Facebook @TaylorStuckHD.



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