DEL.ICIO.USA HIDDEN SHAME: GEORGIA'S MENTAL HEALTH CARE SYSTEM
Unlicensed homes for mentally ill can pose deadly dilemmaPublished on: 12/09/07
The crimes of McDaniel Street filled 45 police reports in October 2006. Broken glass littered the parking lot of a dingy barber shop, which rented its upstairs rooms by the day or the week.
By the time Patricia Cipolla wound up in this rough patch of southwest Atlanta that month, mental illness had sent her to hospitals 74 times in 10 years. The brightly painted blue house at 998 McDaniel, though, offered a fresh chance. Even its name sounded hopeful.
Wellness Retreats.
The home for mentally ill adults promised room, board and supervision of Cipolla's medicines: antipsychotics, vitamins and drugs to control her cholesterol and blood pressure. It came with the blessing of a state-sponsored mental health agency.
"I thought I was doing something good for my mother," says Tria Kreutzer, Cipolla's only child and her primary caregiver for nine years, "not something worse."
Sometime this past summer, Cipolla stopped getting her daily blood pressure and cholesterol pills, her medical records indicate. On Labor Day, Cipolla, 61, was found dead in her room — from a heart condition possibly exacerbated by high blood pressure.
Cipolla's death underscores the scarcity of safe, affordable housing for mentally ill adults in Georgia, an investigation by The Atlanta Journal-Constitution shows.
Wellness Retreats had no license to operate as a personal care home. It wasn't subject to inspection. No one would know whether the home followed the hundreds of rules that govern licensed facilities, including 24-hour staffing, training for employees and clear record-keeping of medicines dispensed to residents.
Unlicensed personal care homes, the Journal-Constitution found, are the last resort for many mentally ill adults who rely on government disability or Social Security benefits to pay their rent and other expenses.
With the state's tacit consent, tax-supported agencies that oversee psychiatric care of adults such as Cipolla sometimes direct their clients into facilities that are operating outside the law. They say they have no choice.
"Quality placements are a major issue," says Sheridan Jackson, a licensed clinical social worker who helped manage Cipolla's care for several months in 2006. "These are not attractive candidates for housing. There are very few licensed personal care homes that will take a seriously mentally ill person who doesn't have a lot of money."
The Journal-Constitution examined the state's reliance on unlicensed homes as part of a larger inquiry into Georgia's mental health care system. The newspaper reported earlier this year that at least 115 patients from the seven state-run mental hospitals died under suspicious circumstances from 2002 through 2006.
Establishing the number of unlicensed facilities or the quality of care they provide is all but impossible. The Georgia Department of Human Resources, which oversees public mental health care, generally does not track living arrangements of adults who receive its services outside the state hospitals.
The department accepts complaints about unlicensed homes but files them by address — a system incapable of keeping up with a home like Wellness Retreats, which has operated from at least nine addresses in the last few years.
Even when investigators determine a home is operating illegally, a violation that carries a fine as high as $25,000, the department rarely imposes penalties. In the year ending June 30, the department received 98 complaints about unlicensed homes. It fined three.
It's a regulatory system short on accountability.
State officials put little effort into determining why Cipolla died. Because state money did not pay for her housing as it did for other services she received, investigators for the state's mental health agency declined to look into her death.
As the investigative unit's director e-mailed to another official: "It is not reportable to us."
A mother and daughter
Mental illness bound Pat Cipolla and her daughter.
Tria Kreutzer's birth in December 1969 was so difficult that Cipolla needed a three-pint blood transfusion. Soon, Cipolla exhibited mood swings and other symptoms of bipolar disorder.
A family photograph from 1977 shows a smiling mother in the New Jersey suburbs of New York, standing beside her dark-haired little girl after her First Holy Communion. A cigarette burns between Cipolla's fingers.
Cipolla and Kreutzer's father had divorced two years earlier; Allan Kreutzer had been awarded custody. Tria Kreutzer remembers visiting her mother on weekends, staying up late watching movies and eating cold pizza for breakfast. Sometimes, she remembers, she visited her mother in the hospital.
Cipolla worked as a legal secretary and lived with her own mother in New Jersey until she died in 1997. By then, Kreutzer had settled in Atlanta. When Cipolla joined her, the daughter became the mother's guardian.
In Atlanta, Cipolla's illness intensified.
Her mother's death devastated Cipolla, who soon had to switch psychotropic drugs after developing kidney problems. The new medicines didn't always control her manic episodes, and she repeatedly went into the hospital, usually for several weeks at a time.
An assertive streak ran through Cipolla's personality, and her voice, with its sharp New Jersey accent, tended to carry. When her medication wasn't working, she could be especially erratic.
Once when Kreutzer was out of town on business, Cipolla wandered to Little Five Points, where she met Jimmy Harbin, who was homeless and an alcoholic. Soon he moved in with Cipolla in her daughter's house. On a whim a few months later, the couple went to the courthouse and got married.
Cipolla and Harbin stayed together for almost two years, until he was diagnosed with terminal cancer in 2006. Deeply depressed and with Harbin in hospice care, Cipolla moved into a licensed personal care home on Howell Mill Road shortly before he died in July. The facility evicted Cipolla after she sneaked out and checked into a nearby Holiday Inn.
Following another manic episode in the fall of 2006, Cipolla entered Grady Memorial Hospital's psychiatric unit. By then, Kreutzer knew her mother needed more than she could give: management of her medicines, structured daytime activities, a place with supervision where she could live on her own.
A social worker at Grady suggested what seemed to be a perfect solution: Georgia Rehabilitation Outreach Inc.
The nonprofit agency, based in Midtown, gets state money — about $13 million since 2002 — to oversee the care of mentally ill adults. It offers day treatment and employs psychiatrists, nurses and social workers who are supposed to make sure clients take prescribed medicines and follow treatment plans intended to keep them out of a state psychiatric hospital. Social workers help find housing, among other services.
Georgia Rehabilitation is one of three private agencies with state contracts to provide a full range of treatment to more than 400 mentally ill adults. The others are in Thomasville and Athens.
About one-third of Georgia Rehabilitation's 200 clients live in personal care homes or similar facilities, says Shirley Hamilton, the agency's chief executive.
"People have a right to live wherever they want to live," Hamilton says.
Neither her agency nor the state checks whether those homes are licensed.
"We don't have a direct responsibility to go around making an official assessment of housing," Hamilton says.
"I have no authority, no expertise in determining whether or not a house is suitable."
Clients of Georgia Rehabilitation have lived in at least one other unlicensed home, state records show. The state ordered that facility, Care Oasis in East Atlanta, to shut down this year after several complaints about living conditions.
State law requires facilities that provide even one "personal service," such as supervising residents' medications, to obtain a license. Although Georgia Rehabilitation's contract does not require it, officials expect such agencies to place clients in licensed homes if they need help with daily living, says Audrey Sumner, the state's director of mental health services.
"If we are making referrals," she says, "we want them to be made to places that can meet the needs of our consumers."
Sumner and other officials decline to comment on Georgia Rehabilitation's handling of Cipolla's case.
Cipolla was the second Georgia Rehabilitation client referred to Wellness Retreats, says Sheridan Jackson, the former social worker at the agency. She says she had learned of the facility from a social worker at Southern Regional Medical Center in Riverdale.
Jackson knew Wellness Retreats lacked a state license. Even so, she thought the home seemed clean and well appointed – by all appearances, she says, a "godsend."
Assisted living
At the blue house on McDaniel Street, Wellness Retreats' director handed Tria Kreutzer a brochure with a photo of a waterfall on its cover.
Wellness Retreats, the brochure said, provided "affordable" assisted living – but was not a personal care home.
It also said: "We supervise self-administration of medication, secure meds, get prescriptions filled and ensure medical appointments are kept."
The home's director, Michelle Edmonds, stressed healthy eating, but Kreutzer says her mother was served hot dogs too often. The home's air conditioning went out during the hottest days of last summer, Kreutzer says.
Kreutzer remembers once telling herself, "It all sounds good, but something doesn't match up."
Every Thursday evening, Edmonds conducted mandatory Bible study for the residents. Cipolla tended to skip the sessions, Edmonds said in an e-mail to Kreutzer, or to sit in a corner reciting Hail Marys.
Edmonds told Kreutzer in another e-mail that she applied biblical principles to manage the residents' mental illnesses.
"Core point," she wrote, "is that mental illness equals selfishness."
Chemical imbalances in the brain, Edmonds wrote to Kreutzer another time, do not excuse "lying and self-centeredness" in people with mental illness. "These are the very symptoms that can be self-controlled. In fact, not only CAN they be self-managed, they are tools consciously USED by mentally ill people to get their way, ENABLING the mental illness even further."
Edmonds declined to be interviewed for this article. In an e-mail responding to a reporter's written questions, she described Cipolla as being "known in the field as a very difficult consumer" who "was on a first-name basis" with psychiatric staffs at Grady and Georgia Regional Hospital/Atlanta.
Edmonds is not a licensed mental health professional, records show, either in Georgia or in New York, where she previously lived. In e-mails, she insisted that Wellness Retreats does not need a license.
"We provide affordable, supportive housing focused on the social habilitation of the mentally ill," Edmonds wrote. Wellness Retreats is an alternative, she said, to "often poorly supervised 'group homes' or to impersonal and/or high-priced institutions."
'People die'
A few weeks after Cipolla moved in late last year, Wellness Retreats closed the house on McDaniel Street and moved the residents to 604 Fletcher St. S.W., half a mile away. The facility moved Cipolla again in August, this time one door down to 610 Fletcher.
Already, Kreutzer was questioning her mother's care.
Cipolla fell and broke an ankle on the stairs, according to her medical records. Cipolla's rent jumped from $560 to $850 after she got a private room, but the air conditioning remained out of order, and she still complained that the food was unsatisfactory.
A social worker and a nurse from Georgia Rehabilitation Outreach visited Cipolla at Wellness Retreats several times during the summer. Their notes say Cipolla needed help with her medicines but do not list the drugs she was prescribed.
At Georgia Rehabilitation's invitation, Cipolla spent two weeks in August at St. Simons Island, learning to counsel peers with mental illness. Georgia Rehabilitation's staff members supervised Cipolla's medicines on the trip. The agency's records don't say what drugs she was taking.
On Aug. 29, shortly after Cipolla returned, Kreutzer went to Georgia Rehabilitation to discuss moving her mother. Cipolla's case manager, Kreutzer says, suggested a licensed home "with more accountability."
Kreutzer was stunned. Until then, she says, "licensing didn't click in my head at all."
That weekend was Labor Day. Kreutzer and Cipolla spent Saturday together, running errands and hanging around Kreutzer's house. Kreutzer took her mother back to Wellness Retreats about 9:45 that night.
Kreutzer last heard from Cipolla in a voice mail message at 7:47 a.m. Sunday, cell phone records show. Cipolla made no more calls.
Kreutzer spent Sunday at the lake with friends. At Wellness Retreats, Cipolla apparently stayed in her room. No one else reported seeing her after 8 p.m.
Cipolla didn't show up for breakfast Monday, or for lunch. She didn't come to the kitchen that morning for her medications. In an e-mail last week, Edmonds said the home's staff assumed Cipolla was visiting Kreutzer for the weekend.
Finally, about 6 p.m., another resident knocked on Cipolla's door. Getting no response, that resident alerted the house manager, who entered the room. Cipolla's body lay face down on the bed. She had been dead, the medical examiner later said, eight to 12 hours. An autopsy determined she died of hypertensive cardiovascular disease.
Kreutzer was immediately suspicious. Her mother had seemed fine just two days before her death. Then, as she probed deeper, Kreutzer clashed with Edmonds.
"You are supposed to be a grieving daughter," Edmonds wrote in an e-mail to Kreutzer, "not an investigator of a crime scene."
Then Kreutzer learned something surprising from the medical examiner: At Wellness Retreats, authorities had found four prescription medications belonging to Cipolla. Two other drugs – including Benicar for her blood pressure – were missing.
Wellness Retreats had been ordering all of Cipolla's medicine refills every month, Kreutzer says. But records from the pharmacy and from Cipolla's Medicare prescription plan show the Benicar was last filled on May 10. The pharmacy delivered a 30-day supply, so Cipolla may not have gotten the blood pressure medicine after mid-June.
It's impossible to tell for sure, though, without records to show what medicines were dispensed and when — records a licensed home would have to keep.
Kreutzer filed a complaint against Wellness Retreats with state regulators. On Oct. 18, an investigator knocked on the facility's door.
The investigator determined that Wellness Retreats had vacated 610 Fletcher St., but was operating next door in a duplex at 1080 Metropolitan Parkway S.W. The investigator found that Wellness Retreats' staff kept all the residents' medicine in a locked cabinet and distributed it each day.
Nevertheless, the department told Kreutzer in a letter the following week: "Based on the investigative findings, the allegation was unsubstantiated and no violations were cited."
The same day, Edmonds sent Kreutzer an e-mail telling her to "stop the threats and harassment."
"You should see by now that your threats and 'official complaints' are not working," Edmonds wrote.
"People die," she added. "Period."
Nightmares
Wellness Retreats stayed in business on Metropolitan Parkway. Then, on Nov. 14, the state investigator returned. This time, according to officials, he issued a citation for operating illegally with no license. The state told Edmonds to apply for a permit or close by Dec. 29.
Last week, the house stood vacant. Nothing was left behind except three worn chairs, a pink pillow and several discarded cigarette packs on the front porch. In an e-mail exchange with a reporter, Edmonds wouldn't say where the residents had gone.
Wellness Retreats, she said, is "in transition."
Tria Kreutzer took her mother home last month. Two days before Thanksgiving, she buried Patricia Cipolla's ashes in Union, N.J.
For the first few weeks, Kreutzer was driven to learn why her mother died. She compiled documents, consulted with lawyers, pressed state regulators to act.
Now, she says, she has begun grieving, and her mother's long struggle and its haunting end give her nightmares.
"About death," she says. "Always death."
UNLICENSED BUT UNPUNISHED
State regulators responded to almost 100 complaints about unlicensed personal care homes in the past year, but penalties were rare.
98: Complaints about unlicensed personal care homes
37: Cases in which complaints were substantiated
16: Homes that closed or moved before investigators visited
8: Facilities allowed to obtain licenses after operating illegally
3: Fines imposed against unlicensed homes
Note: Numbers are for the 12 months that ended June 30.
Source: Georgia Department of Human Resources
ABOUT THIS SERIES
This article is part of an occasional series of reports examining Georgia's mental health care system.
Today's main article, which focuses on Patricia Cipolla, is based in part on interviews with Cipolla's daughter, Tria Kreutzer; on extensive files Kreutzer maintained as her mother's guardian; on e-mails Kreutzer saved; on medical records, an autopsy report, pharmacy files and documents assembled after Cipolla's death; and on interviews with social workers and others familiar with the case.
The yearlong series, by staff writers Alan Judd and Andy Miller, has reported on dangerous conditions in the seven state hospitals. The articles led to an investigation of the hospitals by the U.S. Justice Department, which is continuing. Also, a commission created by Gov. Sonny Perdue is considering changes to the state's mental health care system.
To read the entire series, go to www.ajc.com/hiddenshame.
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