Feds: R.I. child welfare agency warehoused vulnerable kids in hospital for months, even years

U.S. Attorney for the District of Rhode Island Zachary Cunha speaks at a press conference on Monday, May 13, 2024. (Alexander Castro/Rhode Island Current)

She did not leave the hospital. She never stepped outside its grounds. She did not attend school. She rarely saw family or friends.

This young girl who is nonverbal and has developmental disabilities spent a year at Bradley Hospital — one of 527 vulnerable children held at the East Providence psychiatric hospital, most far longer than clinically necessary, according to a two-year investigation made public Monday by Rhode Island’s U.S. District Attorney’s Office.

“As a result of what I can only characterize as this appalling failure, children, particularly teenage girls — rather than receiving the home, foster or community care that is appropriate for their condition and required by law — have been warehoused at Bradley Hospital, an acute care psychiatric institution intended for short-term admissions,” said Zachary Cunha, the state’s U.S. attorney, in a press conference Monday.

Each child was meant to receive short-term stabilization care lasting maybe one or two weeks. But the average stay lasted 51 days. Of those 527 kids: 42 were hospitalized for more than 180 days. Another 116 stayed for at least 100 days. Seven stayed for more than a year, and 197 kids, or 40%, were admitted multiple times. Accounting for multiple stays, the average visit was 92 days per child. 

The longest cumulative stay went to a child who was admitted five different times, for a total of 826 days in the hospital. The next most egregious case was a 14-year-old who spent a total of 706 days there during 11 separate hospitalizations. 

The investigation — a joint effort by Cunha’s office and the U.S. Department of Health and Human Services Office of Civil Rights — began in late 2021 and alleges that the Rhode Island Department of Children, Youth and Families (DCYF) has unnecessarily hospitalized young people with severe behavioral disabilities during the period of  Jan. 1, 2017, through Sept. 30, 2022. Before any possible litigation, Cunha said his office is obligated to offer a letter of findings. The state and DCYF have 10 days to respond to the letter and address corrective measures, which was addressed to DCYF and Gov. Dan McKee.

“The fault we find in this investigation rests with the state, and the state alone,” Cunha said. “We are not alleging any wrongdoing on the part of Bradley Hospital whatsoever.”

Staff at Bradley Hospital often urged state child welfare officials to transfer youth inpatients to less restrictive settings, Cunha said, but their recommendations that children be discharged into family care went unheeded. Combined with “a reflexive use of hospitalization” and “failure for discharge planning,” Cunha said the child welfare department frequently eschewed best practices for over five years. According to the letter of findings, DCYF’s referral process to hospitals was “rapid-fire, haphazard,” and most referrals were sent to the same six to eight providers “regardless of an individual child’s behavioral health needs.” 

“Despite typically needing inpatient services for only one to two weeks, children in the care and custody of the state who had behavioral health disabilities were routinely and unnecessarily segregated in an acute care psychiatric hospital as opposed to living in their communities — for weeks, months, in some cases, more than a year,” said Susan Rhodes, regional director of the U.S. Department of Health and Human Services Office of Civil Rights, at the press conference. 

The feds’ involvement is because of violations of civil rights afforded by the Americans with Disabilities Act (ADA), which dictates that public agencies care for people with disabilities in “the most integrated setting appropriate to their needs,” Rhodes said. That means that public agencies have a duty to care for people with disabilities in ways that minimize their separation from society at large. 

“Unfortunately, cases like this are not new,” Rhodes added. “We see them throughout the country. Children and adults with disabilities both physical and behavioral, have long experienced unnecessary segregation, which perpetuates dangerous assumptions about their ability to participate in community life, directly diminishes their autonomy and may harm their health and wellbeing.”

The nonverbal girl who spent a year at Bradley cannot voice her pain, but the sight of Bradley Hospital from the car window makes her visibly upset and disturbed, her parents said. Now her parents take a detour, driving carefully to avoid the hospital’s appearance in the landscape, according to the U.S. attorney’s letter of findings.   

“If you have children, it’s not hard to envision how devastating what we found here is,” Cunha said Monday afternoon. “Frankly, if you have empathy, it’s not hard to envision how devastating this is.”

Cunha reiterated that his office did not find any issue with Bradley Hospital’s quality of care or its clinical competency. 

“The medical records demonstrate this point: the longer children stay at Bradley, the more their behavior deteriorates,” the letter of findings reads.

“DCYF takes these findings very seriously and is committed to continuing to work closely with the U.S. Attorney’s Office and the U.S. Department of Health and Human Services to reach a resolution in the best interest of the youth in DCYF’s care,” said Damaris Teixeira, a DCYF spokesperson, via email. “We agree with the report that more work is needed on addressing the behavioral health needs of children in Rhode Island.”

Overwhelmed by demand for services

Complicating DCYF’s placement practices is that the agency does not care strictly for foster children or other youths who are solely wards of the state. Children needing behavioral health treatment can also access DCYF services via agency referral and at their parents’ request. These referrals can lead to 122 different services, the U.S. attorney noted, with residential treatment, hospitalization or 34 different “community based services” all available options.  

“However, most of these services are not available in sufficient quantity or intensity…and there are long waits for children to access such services,” according to the letter of findings. “Furthermore, we found that DCYF is not actively monitoring the capacity or taking systemic steps to proactively address the insufficient capacity of its current network of community-based providers to fully meet the demand for various community-based services.”

DCYF Director Ashley Deckert, who took over the department in May 2023, seemed to agree when she spoke to the Senate Committee on Finance on March 5. “I have some ideas around how we don’t have to be dependent on the use of residential treatment facilities,” Deckert told lawmakers. “We’re better served figuring out a continuum of care or a system of care that doesn’t encourage increasing capacity by actually addressing the issue and getting the youth into a least restrictive setting.”

Unfortunately, cases like this are not new. We see them throughout the country. Children and adults with disabilities both physical and behavioral, have long experienced unnecessary segregation, which perpetuates dangerous assumptions about their ability to participate in community life, directly diminishes their autonomy and may harm their health and wellbeing.

– Susan Rhodes, regional director of the U.S. Department of Health and Human Services Office of Civil Rights

According to the letter of findings, DCYF lost half of its therapeutic foster care parents when it changed its rate structure in August 2020, which led to lower reimbursements that no longer incentivized trained providers. 

DCYF has also failed to leverage “federal funds or resources across state agencies,” the investigation alleges, which has led to an “overreliance” both clinical and financial on residential and hospital-level care compared to community-based options. In fiscal year 2020, the state spent nearly $14 million in Medicaid money on psychiatric hospitalizations for kids. In fiscal 2021, the state spent $27 million on residential treatment facilities.

The U.S. attorney’s findings seem to echo a much-discussed 2023 investigation and report by the Office of the Child Advocate, which oversees DCYF. The Child Advocate suggested that even at a sub-hospital level of care — specifically, at the North Providence residential treatment facility St. Mary’s Home for Children — DCYF used a “No eject, no reject” clause in its contract to broaden the scope of eligibility and ensure placements regardless of individual need.

“The process has been described as ‘throwing something against the wall and if it sticks, it’s the right place,’” the Child Advocate’s report stated. 

In 2018, Rhode Island submitted and received federal approval for a Medicaid extension that allows otherwise Medicaid-ineligible youths with serious emotional distress to be treated in a psychiatric residential treatment facility like St. Mary’s without parents relinquishing custody.

The Office of the Child Advocate provided a statement to Rhode Island Current Tuesday afternoon: “All children involved with DCYF have the right to receive treatment in the least restrictive setting with access to comprehensive services that allow them to maintain relationships with their family, school, and within the community,” the advocate’s office said. “These findings provide a critical opportunity to conduct an in depth review of our full continuum of care, build capacity in-state, and explore all funding opportunities.”

The advocate also said limiting hospital admissions and “timely discharge”  to suitable step down care should be prioritized alongside the expansion of prevention and community-based efforts.

The U.S. Attorney also challenged a much-repeated notion from the state’s child welfare officials: that there aren’t enough beds in-state for intensive psychiatric placements. 

“It’s not an issue of not enough beds,” Cunha said. “This is not a problem that can be solved by building more bed capacity. The problem is the use of hospitalization when less restrictive means are available necessarily like community care, like therapeutic foster care settings that don’t involve actually confining a child to a hospital.”

Morna A. Murray, executive director of Disability Rights Rhode Island, the state organization federally tasked with disability advocacy, said in an emailed statement: “We agree that robust community-based services are critical to address this long-standing warehousing of children and youth in hospital facilities in our state,” Murray wrote. 

“The answer is not more hospital beds, regardless of the size of the facility. This federal investigation mirrors what DRRI has uncovered about youth consigned to St. Mary’s Home for Children: Children languish in institutions, settings that exacerbate harm and distress, and this is a violation of their legal and civil rights.”

Olivia DaRocha, spokesperson for Gov. McKee, called the report “troubling” in an email, acknowledging Rhode Island is impacted by a national shortage of home and community-based behavioral health services. 

“While our Administration has taken actions to improve our current placement system, we understand that more must be done, and we support DCYF’s continued cooperation with the U.S. Attorney and the U.S. Department of Health and Human Services,” DaRocha wrote. “Together, we will continue to seek short- and long-term solutions to provide each child with a behavioral health disability the appropriate services in the most integrated setting.”

Statement from Rhode Island Department of Children, Youth and Families

The following response was released to Rhode Island Current Monday, May 13, 2024, at 6:33 p.m:

“Today, the U.S. Attorney’s Office shared with DCYF the findings of an investigation that reviewed youth in DCYF care who were treated at Bradley Hospital between the years of 2017 to 2022. 

DCYF takes these findings very seriously and is committed to continuing to work closely with the U.S. Attorney’s Office and the U.S. Department of Health and Human Services to reach a resolution in the best interest of the youth in DCYF’s care. We agree with the report that more work is needed on addressing the behavioral health needs of children in Rhode Island. 

Under the current Administration, the State has taken steps to begin addressing the issues outlined in this report. Starting in November 2022, and continuously since, the Department has worked with Bradley Hospital and Hasbro Children’s Hospital to expedite discharges to appropriate placements as quickly as possible.  

Over that same time period, the Mobile Response and Stabilization Services (MRSS) program was launched. This program provides time-limited, on-demand crisis intervention services in any setting in which a behavioral health crisis is occurring, including homes, schools and emergency departments. Depending on the needs of the child, the stabilization component may include a temporary, out-of-home crisis resolution in a safe environment. To date, 90% of the youth in this pilot program did not end up requiring psychiatric hospitalization.

To address the need for more residential beds, to provide step-down care for youth who have been hospitalized, the state is investing approximately $45 million to expand in-state residential capacity, including a facility in Exeter that will serve 16 youth. Additionally, the state legislature appropriated $11 million for the building of a 12-bed psychiatric residential facility (PRTF) to address in-state capacity need.”

This article was updated on Tuesday, May 14, to include a comment from the Office of the Child Advocate.

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