An expected application by a private company seeking to place a long-term care facility for patients transitioning out of psychiatric hospitals in a south Centralia neighborhood touched off a lengthy discussion at Tuesday’s Centralia City Council meeting.
It likely won’t be the end of debates over the issue.
The council passed a resolution Tuesday enacting an interim zoning ordinance through an emergency process for a six-month period relating to residential care services and the special use permit process. The move came after a review of city code prompted by a pre-application meeting with Noble Healthcare, LLC to renovate the abandoned Sandra Care Assisted Living Facility at 1215 S. Tower Ave. into an Enhanced Services Facility.
An Enhanced Services Facility (ESF) is a relatively new form of residential care facility in Washington state. The four currently in operation — two in the Spokane Valley, one in Vancouver and one in Everett — are licensed by the state Department of Social and Health Services and house a maximum of 16 persons. Residents are those deemed ready by the state to transition out of state or psychiatric facilities, such as Western State Hospital, or who require specialized behavioral or mental health care that does not require them to be institutionalized.
“We have a crisis and we have a need,” said Kristin Byrne, deputy director of the community living and support systems arm of the state Home and Community Services division. “We hope we will have more ESFs in Washington state.”
Byrne testified at Tuesday’s meeting along with Candace Goehring, director of residential care services for the Aging and Long-Term Support Administration under the umbrella of DSHS, and Zach Wester, one of three brothers who own and operate Noble Healthcare.
Bea Rector, director of the HCS division of DSHS, signed a letter sent to the city council in support of the proposed ESF in Centralia. Dated April 9, the letter states the state legislature funded the development of ESFs in 2013, with the first opening three years later.
“Individuals in an ESF benefit from enhanced levels of professional staff to assist with bathing, dressing, personal hygiene and medication reminders, in addition to behavioral supports to assist these individuals to successfully live in the community,” Rector wrote.
Western State Hospital lost $53 million in state funding last year after failing to meet federal care requirements for its patients. More than 150 nurses there signed a letter of no confidence late last year after a rash of injuries to care providers suffered at the hands of patients. One nurse reportedly had her earlobe bitten off by a resident while he was choking her.
A Frequently Asked Questions document on the Aging and Long-Term Support Administration portion of the state DSHS website states, “Our current focus is on finding placements for clients who are ready to discharge from Western State Hospital; development of an ESF along the I-5 corridor is a priority.”
The Mental Health Transformation Initiative undertaken by Gov. Jay Inslee last year is meant in part to spur development of residential facilities for persons able to transition out of state hospitals.
“(Housing and Community Services) is responding to the Governor’s initiative for behavioral health transformation,” said Kristin Byrne, a deputy director in the Community Living and Systems Support arm of HCS.
Centralia City Attorney Shannon Murphy-Olson said Wednesday that if Noble Healthcare applies for a special use permit in the coming days — something it would need to operate on the Tower Avenue location — they’ll operate under the process spelled out in the interim code passed Tuesday by the council. Their application will be reviewed by a committee and be subject to a public hearing before going in front of the city’s hearings examiner — James Buzzard — who will issue findings of fact.
The interim changes to city code passed Tuesday will also be subject to a public hearing scheduled for May 14 during the regular city council meeting. The city council will not have the ability to approve or reject the special use permit once it is under review, though it could attempt to pass an ordinance restricting where an ESF can be located, similar to the zoning requirements for retail marijuana outlets.
Community Development Director Emil Pierson said there is no set deadline for a public hearing to take place once Noble Healthcare files its application. It will depend on how long it takes to go through the initial review and the schedule of the hearings examiner, among other factors.
“We just have to look and decide where the best places are to site these,” Murphy-Olson said. “We’re trying to determine right now where the most appropriate places are. I think in this particular situation, they located the old facility that would work, and I think that’s what attracted them to the location.”
Though the vote taken by the city council did not have any bearing on whether Noble Healthcare could proceed with a special use application, a separate process that includes a public hearing, councilors chafed at the criteria ESF residents must meet as listed under the Revised Codes of Washington Chapter 70.97.
Eligible persons must have at least one of the following: a mental disorder, chemical dependency disorder, significant brain injury or cognitive impairment requiring supervision and facility services. They must also be deemed to require the daily care of a nurse, mental health or chemical dependency professional, or require assistance with at least three basic activities such as getting dressed or brushing teeth.
Patients who meet those two requirements must also be flagged for two or more of the following complications: self-endangering behaviors that are frequent or difficult to manage; aggressive, threatening or assaultive behaviors that create a risk to the health or safety of other residents, staff or property; intrusive behaviors that put residents or staff at risk; complex medication needs that include psychotropic medications; history or likelihood of unsuccessful placements in a licensed or state facility; history of frequent or protracted mental health hospitalizations; history of offenses against a person or felony offenses that created substantial damage to property.
Persons who reside in an ESF meet the definition of a vulnerable person as defined in RCW 74.34. City Councilor Peter Abbarno took issue with the way representatives from DSHS and Noble Health framed the clientele just as persons with complicated medical needs who require assistance with basic activities. Byrne responded that the clients currently being served by ESFs are not a close reflection of the more eyebrow-raising aspects of the RCWs.
“I think that as we go through this process, we just need to be honest and have these public discussions of accurate definitions of persons who may be staying in these facilities, our neighborhoods and our communities,” Abbarno said. “I think it’s more than just vulnerable adults who need help bathing. I know we’ll get into these details as we move through the process, but I think people need to know what the definitions technically are, so we can move forward honestly.”
State law mandates strict licensing requirements for ESF operations, sometimes requiring standards of care above those for other assisted living facilities.
A ratio of at least one staff member for every four residents of an ESF must be maintained, with a minimum of two staff members awake at all times. A mental health professional is required to be on site at least eight hours per day, with one on call and available to respond within 30 minutes of being contacted.
Wester, Goehring and Byrne emphasized that clients deemed eligible for ESFs go through rigorous screenings to develop a care plan that balances their level of independence with their need for supervision or restriction. Staff must complete a comprehensive assessment of a new resident within 14 days of admission and review the findings at least once every six months.
Eligibility for Medicare or Medicaid is another requirement for successful application to live in an ESF. Those programs pay the bulk of the cost — listed at $425 per day per the online FAQ — though clients contribute if they receive income via sources such as Social Security.
The facilities are not locked from the inside like a memory care or psychiatric ward may be. Residents may be afforded the freedom to leave on their own if care providers deem them capable of doing so without being a danger to themselves or others. Other residents may require supervision by staff or a family member while in public.
Assurances that staff are trained in crisis management and de-escalation techniques did little to calm the worries of councilors such as Sue Luond, who asked if there had been any incidents of harm in the current ESFs. None are reported on the DSHS website and Goehring could not recall any such instances.
“My biggest concern is that mental illness is something that nobody can predict exactly, even the best professionals,” Luond said. “It would just take one victim to tear this community apart if someone got out and went haywire, if someone wasn’t completely under some sort of supervision. Even though I’m sympathetic to the problem, because I know there’s a problem, I’m concerned with the fact that they’re allowed, with this level of dysfunction, to be out in the public.”
Luond’s concerns have been shared by citizens of cities where Noble Health has attempted recently to receive approval for similar ESF projects.
Burien residents turned out en masse for a public hearing on Jan. 10. Hundreds of people attended the meeting, which lasted more than two hours and had to be moved to a larger space to accommodate the crowd. Tensions flared as the discourse devolved at times into a shouting match, according to the B-Town Blog.
The owner of the building Noble Healthcare sought to purchase wrote a letter opposing the project and the brothers backed out of the sale later that month. The company has also approached the city of Des Moines about operating an ESF there.