SWITC again sees demand for more staff amid Medicaid compliance issues

Southwest Idaho Treatment Center in Nampa. (Photo courtesy of OPE)

By Ruth Brown, Idaho Reports

The Southwest Idaho Treatment Center, a state-run facility with a troubled past, is again seeing a shortage of staff available to help clients, an issue that could jeopardize its licensing and ability to accept federal funding.

The Nampa facility, commonly called SWITC, is a temporary home to intellectually disabled and mentally ill people who cannot stay in an in-home situation, often because of dangerous or aggressive behaviors.

The facility faced complaints in 2021, and the Department of Health and Welfare’s Bureau of Facility Standards determined it was out of compliance with federal standards, according to copies of the surveys. 

A timeline of licensing reviews

The bureau reviewed the facility on March 26 to follow-up on complaints from January, and found it to be out of compliance with Medicaid Intermediate Care Facility for Individuals with Intellectual Disabilities rules, according to a copy of the notification. 

Issues ranged from staffing shortages to investigating potential abuse.

In a March 30 letter, Nicole Wisenor of the Bureau of Facility Standards notified SWITC of “substantial noncompliance” representing a serious and immediate threat to individuals.

In May, the Centers for Medicaid and Medicare Services said the plan for correction submitted by SWITC was acceptable. 

On April 15, an on-site verification of the plan confirmed its status of being in “immediate jeopardy” of losing Medicaid was lifted.  

Idaho Reports reached out to the Idaho Department of Health and Welfare and they verified SWITC has 13 clients, one of whom is a minor, as of Oct. 25. 

Following the deficiencies, SWITC moved three patients out of the area with the intermediate care facility for individuals with intellectual disabilities license — or ICF/IID license — and into crisis beds. That means those three patients’ care is not paid for with the federal Medicaid match, and the state pays for the entirety of their care.

Since those three people’s care is now entirely paid for by the state, it could cost roughly $2 million if it carries on through the year, said Cameron Gilliland, Health and Welfare Administrator of Family and Community Services.

Medicaid care is generally paid for by roughly 70% federal funding and 30% state funding. That varies in different states.

On June 29, inspectors conducted a follow-up visit and found no deficiencies at SWITC. 

The issues this year are not SWITC’s first deficiencies. The facility in September 2019 was again found to be out of compliance with federal standards. The facility submitted a plan for correction in January of 2020. The 2019 violations were similar to those in March 2021, and staffing was again listed as an issue.

As of Oct. 25, Medicaid is accepted at SWITC and they are in compliance with federal standards.

Gilliland said one of the issues with the survey was the dated type of licenses issued for ICF/IID facilities.

He said initially those licenses were intended to be used for long-term care facilities, but SWITC really is a short-term, treatment-focused facility. 

Compliance issues

The March survey included interviews with staff. One stated “both individuals and staff expressed concerns with the facility’s staffing and its impacts on community utilization and managing maladaptive behaviors.”

The survey also outlined some violent behaviors that certain clients were prone to, making the clients challenging to manage and treat. The survey outlined incidents when clients hit, bite and threw things at staff members.

Other reported incidents involved clients verbally or psychologically abusing other clients, or staff attempting to stop clients from hitting their head. Some clients made threats, such as “I’m going to kill you.” 

“Clients do yell at each other and it’s hard to stop that,” Gilliland said when asked about the survey findings. The facility has since separated out three clients who were especially problematic.

Those three clients are given the same care, but are kept apart from other clients, he said. 

All of the clients at SWITC require varying levels of supervision, based on behaviors and threats of self-injury.

Another client reportedly made statements about self-harm, such as “hurt self” and “wanna die” but was not placed on the suicide prevention policy, according to the survey.

The March survey outlined the facility’s failure to ensure that all reports of abuse, neglect or mistreatment are fully investigated and a failure to ensure corrective action is taken if an allegation is substantiated. The survey also took issue with a complaint that SWITC was not ensuring patients’ religious rights were upheld.

The survey found that visitation of clergy members was denied during the pandemic, despite guidance around compassionate care. One SWITC client’s guardian requested a visitation for religious purposes in 2020 and was denied due to restrictions on visitation.

During the COVID-19 pandemic, the facility halted in-person visitation with clients, but state guidance still allowed for visitation for “compassionate care.” The survey stated compassionate care does not only apply to end-of-life. It can also apply to residents struggling with grief, emotional distress or behavioral disturbances.

The survey said SWITC did not ensure policies were developed for compassionate care visitation situations.

Since the beginning of the pandemic, Southwest District Health has reported 42 coronavirus cases associated with SWITC, with no hospitalizations or deaths from the cases.

Gilliland stressed that he is proud of the staff, saying “when people come to (SWITC) they are often in the biggest crisis of their lives” and staff are dedicated.

Many of the clients at SWITC would not be accepted at any other facility because of how challenging their behaviors can be, he said. 

“The treatment given at SWITC is above and beyond any other,” Gilliland said. “We have gone to great lengths to keep people safe.”

SWITC’s History 

The legislature received recent recommendations from the SWITC Advisory Board, which was formed after a variety of problems became apparent at the facility in 2017.

In 2019, the Idaho Office of Performance Evaluations released a report on SWITC after the facility gained statewide attention. 

In 2017, SWITC reported that six employees left after repeated incidents of abuse or neglect, including a client who died by suicide and wasn’t found for several hours, and failed inspections which threatened the facility’s federal funding.

After the client suicide, the coroner reported that the client had been dead for six or seven hours, despite staff documenting that they had checked on him every 30 minutes, according to OPE.

Staffing the facility has been an ongoing issue. This is in part because of low salaries, but also because the clients there can be challenging to care for in that setting. According to OPE’s report, “For the first half of 2018, one in 10 staff days was spent out on injury; on one shift that number was one in five.” OPE reported that “for six of the first nine months in 2018, SWITC lost more staff than it hired.” 

OPE’s report focused on some of the trauma endured regularly by staff at SWITC. At the time, they reported being spit on, assaulted, screamed at, subjected to racial or homophobic slurs, or being left in situations where they didn’t have backup to help when clients acted out.

Legislative challenges

On Oct. 19, Jill Randolph with Legislative Services told legislators on the Joint Finance-Appropriations Committee that there were currently 38 vacancies at SWITC, causing some staff to work overtime. The Department of Health and Welfare hopes to increase pay rates and offer retention bonuses for existing staff. 

Gilliland said Monday that some of those vacancies have been filled.

The department asked for a fiscal year 2022 supplemental appropriation of $65,000 for recruitment and retention of staff. 

IDHW’s budget also requests $13.1 million for a remodel at SWITC. The budget request states the money would be used “for the building of an Observation and Assessment Unit and Step-Down Housing on the SWITC campus. These care settings are necessary to support the new system of care for individuals who have developmental disabilities and complex behavioral issues. The care settings and treatment services have been recommended by the SWITC Advisory Board and will replace the current Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) facility.”

Gilliland said part of the goal is to help train clients to rely on less support and eventually be able to go back out into the community, rather than live in a hospital-style environment.

When the Idaho Legislature reconvenes in 2022, budgeting issues will be discussed in further detail. 

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