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VOR Weekly E-Mail Update
July 7, 2006
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Table of Contents

FOCUS ON CALIFORNIA

1. Broken Homes - an investigative series on the state of community homes
in the Bay area

FOCUS ON MISSOURI

2. St. Louis Post-Dispatch Series: Broken promises, broken lives
3. Families fight to keep state facilities open
4. Private facilities are not held accountable

JOIN VOR - A form is at the end of this Update. Thanks!

Coming Up: There will be no VOR Weekly E-Mail Update published on Friday,
July 14, 2006.
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FOCUS ON CALIFORNIA
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1. Broken Homes - an investigative series on the state of community homes
in the Bay area
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California
Inside Bay Area, July 3 -- 5, 2006
Broken Homes
 
Some 26,000 of California's 200,000 developmentally disabled residents --
people who are mentally retarded, have Down syndrome, are autistic or have
other disabilities -- get some type of community-based care, state data
show, and many of them are in licensed care homes which are in residential
neighborhoods all over the state. 

Many have been placed in care homes over the past dozen years, as the state
emptied its institutions.
Two state institutions for developmentally disabled people closed in the
late 1990s and a third, Agnews Developmental Center in San Jose, is slated
for closure in the near future.

The investigation shows a care system whose low standards, poor funding and
limited oversight spell trouble for the more severely disabled people it is
now expected to serve - people the system was never set up for in the first
place. And it shows that the state agency ultimately responsible for the
welfare of the developmentally disabled - some of the state's most
vulnerable people - has little direct involvement in their care.   the
investigation of 300 care homes in Alameda, Contra Costa and San Mateo
counties, which included more than 100 interviews and analysis of thousands
of pages of public licensing reports and other documents spanning back to
1999. 

See for the com, http://www.insidebayarea.com/brokenhomes

NOTE: VOR's Abuse and Neglect Document is regularly updated. See
http://www.vor.net/abuse_neglect for the most recent version.

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FOCUS ON MISSOURI
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2. St. Louis Post-Dispatch Series: Broken promises, broken lives
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A Post-Dispatch investigation has found abuse and neglect of mentally
retarded and mentally ill residents in state centers and in private
facilities the state supervises. Since 2000, there have been more than
2,000 confirmed cases of abuse and neglect with 665 injuries and 21 deaths.
Two articles from this 4 day, 10 article series follow. The full series can
be accessed at
http://www.stltoday.com/stltoday/news/special/abuse.nsf/Front?OpenView&Coun
t=2000.

NOTE: VOR's Abuse and Neglect Document is regularly updated. See
http://www.vor.net/abuse_neglect for the most recent version.

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3. Families fight to keep state facilities open
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By Carolyn Tuft and Joe Mahr
ST. LOUIS POST-DISPATCH
06/12/2006

Families of mentally retarded Missourians have rallied on the Statehouse
steps, produced DVDs and booklets, and staged press conferences for years
-- all to try to convince the governor of one thing: They trust state
institutions to take care of their relatives.

"We know what is best for our loved ones," said Ron Wehmeyer, a parent
who's helped coordinate the rallies.

Despite the notorious reputations of state-run institutions, residents'
families have lobbied to keep them open because they say it would be more
dangerous for them in privately run facilities. They're taking on the
courts, researchers and advocates for the disabled who argue the opposite.

It's an emotional battle being fought as well in Illinois and across the
nation, and issues of mistreatment are cited by both sides as proof each is
right.

Advocates for closing state institutions argue that large institutions
breed cultures of mistreatment that can be easily hidden from the public,
and they cite injuries and deaths uncovered at places such as Bellefontaine
Habilitation Center in Bellefontaine Neighbors and the now-closed Lincoln
Developmental Center in central Illinois.

Put residents out in smaller homes nestled in communities, where mentally
disabled residents are more visible, and mistreatment can't be hidden as
easily, said Marsha Koelliker, with the Illinois watchdog group Equip for
Equality.

"You will have people who see it," she said. "You'll get calls from
hospitals, from teachers, from plumbers, from paramedics."

But criticism has mounted for more than a decade over how states monitor
private homes.

While large, state-run facilities are inspected by federal regulators, the
federal government allows the states to oversee most smaller, privately run
places. And as early as 1993, a congressional committee complained that
states had no idea of problems in private group homes until after
tragedies.

Ten years later, the Government Accountability Office said the federal
government still hadn't forced states to ensure the safety of residents in
private facilities.

Those complaints of a lack of oversight join horror stories from families
who say their loved ones suffered in private facilities where poorly
trained workers couldn't handle them. With the help of unions representing
state workers, movements across the country push to keep state-run
institutions open. Illinois considered reopening Lincoln center until
opponents pressured Gov. Rod Blagojevich to scuttle the plan.

Missouri Gov. Matt Blunt has pushed for the opposite. He wants to close
Bellefontaine. So far, family groups have convinced the Legislature to keep
funding it. But the groups fear that the state will one day close all its
institutions.

Natalie Woods said she watched her mentally retarded sister suffer in
private care in the Springfield area until being transferred to a state-run
center 100 miles away in Nevada.

"There is nothing more my family would love than to have my sister in
Springfield in a group home ... but we have to face reality," Woods said.
"I can only go on what we've experienced in the past, so why would I want
to turn our lives and hers upside down?"

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4. Private facilities are not held accountable
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By Carolyn Tuft and Joe Mahr
ST. LOUIS POST-DISPATCH
06/12/2006

Gary Oheim lay in a group home as bed sores eroded his skin to the bone and
filled his room with the smell of rotting flesh.

The smell should have been a warning sign to the state caseworker assigned
to do monthly checks on the mentally retarded man. But the caseworker had
been to the privately run facility only once in three months, the state
said, and then didn't check on Oheim.

The Department of Mental Health didn't learn about Oheim's condition until
a worker in that southwest Missouri home complained. By then it was too
late. Twenty days later, Oheim died in a Bolivar hospital. He was 40.

Missouri had failed to follow its own rules to supervise the private
companies and nonprofit agencies it entrusts with the vast majority of
clients requiring full-time care.

Advocates for the disabled often focus on the mistreatment uncovered in
state-run institutions. But it is in private industry - particularly in the
housing and care of mentally retarded people - that most complaints and
investigations occur, where most injuries are logged, and where most deaths
have been blamed on poor care - 14 of the 21 deaths of full-time residents.

A Post-Dispatch investigation has found that Missouri's system to catch
abuse and neglect at private facilities for mentally retarded residents is
in some key ways worse than the state's often criticized practices in
policing its own institutions.

Among the findings:

Caseworkers are considered the eyes and ears of the Mental Health
Department oversight system, yet some consistently fail to meet with
clients at least once a month, as required.

State auditors have repeatedly found times when private facilities did not
report suspicious incidents, as required, and state overseers did not
investigate reports that were submitted.

The state takes twice as long to finish investigations in privately run
facilities as it takes at its own institutions.

The state has failed to revoke licenses of facilities where workers
committed deadly lapses, and has failed to ensure workers who have
mistreated residents don't get jobs at other places and abuse again.

The Department of Mental Health's own review of its oversight flaws found a
system that "really is stretched," said Clive Woodward, the department's
director of quality outcomes.

"We were looking for opportunities for improvement, and we have plenty,"
Woodward told the department's oversight commission last week.

The strain on the oversight system is expected to get only worse.

Taking part in a four-decade national movement to shutter institutions,
Missouri now houses five times as many people in private facilities as ones
run by the state - with pressure by many advocates to increase that ratio.

Most mentally retarded Missourians still live at home with their parents.
As the parents die, experts predict the state will be asked to find places
to house thousands more in a system that already is struggling with tighter
budgets, bigger caseloads and waiting lists.

Fewer checks, more paperwork

When the Legislature created the Department of Mental Health in 1974,
abuses at large, public institutions had grabbed headlines across the
country, and advocates were pushing states to shift money and residents
into smaller, privately run group homes that they said would boost the
quality of life of residents.

The new state department took over control of the older state institutions,
and began regional centers to police the new group homes sprouting across
the state. The regional centers assembled an army of state caseworkers -
called service coordinators - to check on every resident in every facility
at least monthly.

But there has been an explosion in the number and types of group homes,
particularly over the last decade, and the ranks of caseworkers are
stretched thin trying to oversee a mix of corporate facilities, nonprofits
and "mom-and-pop" operations.

Mental Health Department officials acknowledge that caseworkers at some of
the 11 regional centers must oversee the care of up to 80 residents.
Officials estimate that 10 percent of caseworkers aren't making the
required visits each month and others are so busy reviewing required
paperwork at the homes that they have little time to visit with the
residents.

"They're very valuable staff, and they are really feeling beleaguered right
now," said Linda Roebuck, the interim director of the division overseeing
services for mentally retarded residents.

As far back as 2001, the state auditor's office - a separate watchdog
agency in Missouri government - warned of inconsistent policies and
practices throughout the state.

Caseloads for caseworkers averaged 41 to 75, depending on the location,
with at least one St. Louis caseworker forced to oversee the care of 139
people in private facilities and homes, auditors reported.

The regional centers also have special quality assurance teams that are
supposed to check the performance of privately run facilities every three
months, but auditors found they had no standards for staffing them.

Poplar Bluff had 13 staffers to oversee care for about 1,100 people. St.
Louis' three-person team was to look after more than 9,100.

In the middle were places like the Springfield regional center, which had
seven staffers to watch out for 2,200 residents.

One of them was Oheim.

His cerebral palsy had left him immobile and susceptible to bedsores if his
caregivers didn't move him and clean him regularly.

That's what the attorney general's office later discovered had happened to
Oheim in the fall of 2001 at Turtle Creek Group Home in Bolivar. Right
after Thanksgiving, his bed sores had broken open. He was in constant pain
and his body started to smell, according to court records.

Workers said the supervisor of the home, Mary Collura, claimed to be taking
Oheim to the doctor when she wasn't, court records show. But no one would
know of Oheim's troubles outside the home. That fall, his caseworker
visited once, on Nov. 9, 2001, and didn't see Oheim, according to mental
health officials.

A month later, the regional center's quality assurance team did its
three-month review of the six-resident facility, but didn't note any
problems with the care of Oheim, according to Mental Health Department
records.

It took a new worker at Turtle Creek to complain to Collura's boss, who
called the Mental Health Department. That was Jan. 9, 2002, when Oheim's
weight had dropped to 108 pounds.

Oheim's death later that month sparked a rare investigation of abuse and
neglect by the attorney general's Medicaid fraud unit.

Collura pleaded guilty in February 2006 to involuntary manslaughter and is
serving five years in prison. Six other workers pleaded guilty to lesser
charges, and charges against the home's corporate owners are pending.

The state eventually shut down the home for other reasons, and the
caseworker was suspended for six months and later quit the agency.

"It should not have happened the way it did," said Roebuck, who took over
running the department this year. "There was some confusion at the time."

Mental health officials say they have been trying to lighten caseloads and
partner more with local government agencies to boost oversight, and they've
been working for years to revamp policies and procedures on the quality
assurance teams.

But it's clear that the problems have continued.

Last fall, employees of the state auditor's office walked into the Sagamont
Group Home for seven in southwest Missouri and found broken furniture,
unpackaged food on shelves, an exposed electrical outlet and dirty rooms.
Caseworkers who visited the home in the previous two weeks hadn't noted any
of the problems.

Also troubling was what happened four days before they visited, the
auditor's report said. A resident who was supposed to be kept away from
dangerous, ingestible chemicals drank a bottle of hairspray and had to be
hospitalized.

The group home notified the Mental Health Department, which ordered the
home to start locking up hygiene products after each use. But the day
auditors visited - three days after that order was issued - the products
were still scattered about a bathroom shared by residents.

No one from the regional center had stopped by to ensure the orders had
been followed.

Not getting reports

Even if a caseworker checks on clients every 30 days, no one from the state
is around the rest of the month.

The data, at first, suggests there's not nearly as much to worry about in
private facilities compared to state ones. The numbers of incidents are
higher in the private system, but when compared to the caseloads, the rate
of confirmed mistreatment is only a fourth of the rate for people in state
care.

That's if the numbers are accurate.

In a report released last fall, the state auditor's office found "numerous
examples" of incidents not being entered into the state's incident tracking
system - either by private facilities not submitting reports, or by
regional center staff not entering them into the computer. It was a
follow-up report to the earlier review by the state auditor's office, which
found caseworkers at one regional center threw away incident reports before
they could be entered into the tracking system and investigated.

Left in the void are investigations that never happened, such as the case
of Matthew Mell.

The mentally retarded man was transferred among 14 facilities in two years,
his family said.

At a group home in Springfield, he began drinking gallons of fluids and
wetting the bed, quickly lost 30 pounds, and had behavior so erratic he
pushed his mother down, breaking her shoulder, his family said. He finally
collapsed one day in 2000 and was rushed to the hospital, where doctors
found he had undiagnosed diabetes.

Mental Health Department policy calls for caregivers to ensure residents
receive needed medical care, but there's no record the incident was
reported, as required, or investigated.

There's also no record of an investigation of an alleged sexual attack of
Mell at a group home in Nixa.

"My parents got a call that one of the workers had attacked him sexually,
and they (the group home) didn't want to be responsible for him," said
Mell's sister, Kristal Lindstrom.

Lindstrom said the family was told the attacker was a worker recently out
of prison, but they weren't told exactly what happened - just that Mell
needed to be placed somewhere else.

They tried other places, including a nursing home in Ozark, where his
family said staffers trying to control him punched him and broke his
glasses in 2001. Such altercations are supposed to be reported. Again,
there's no record of the allegation, according to the Department of Mental
Health.

Nor is there a record of anyone investigating how nearly $1,500 worth of
video games were stolen from his room there.

Lindstrom, her brother's guardian, successfully fought to get her brother
into a state-run institution in Nevada. She said his behavior is now under
control and he's much safer.

She has testified about the alleged mistreatment of her brother in front of
state lawmakers.

The Department of Mental Health has never questioned the accuracy of the
family's public complaints. They haven't checked into them either,
officials acknowledged.

The lack of reporting doesn't surprise Patricia Campbell.

She has run group homes around Poplar Bluff for more than three decades and
has watched the number of homes explode as the federal government has
loosened the rules about how Medicaid money can be spent to care for the
mentally disabled.

While she said many facilities are well-run, she knows that it's easy for
bad facilities to hide abuse or neglect.

"If you have a nice building, they will give you the license and they will
give you clients, and they will tell you how to keep the paperwork going,"
Campbell said. "But nobody comes in and sees if the person that you're
supposed to be caring for is being cared for."

If a resident gets mistreated or injured, nobody from the state is there to
see it.

"If you don't write up a report and they don't come out and check," she
said, "who's going to know? Nobody."

Not investigating

Even when facilities do report, the department takes twice as long to
investigate complaints in the private facilities as in its own, according
to an analysis of case data.

Department officials cite myriad reasons: It's harder to track down
witnesses in private facilities, private facilities keep different types of
records, and federal rules now require investigations in the state-run
facilities to be done in five days.

"It's harder to have the direct control in a community provider to complete
this," said the department's medical director, Joseph Parks.

And not every complaint is entered into the system to trigger an
investigation.

One facility in St. Joseph dutifully faxed the state a neglect report in
November 2004. A resident who was supposed to be watched constantly had
wandered away and into a neighbor's living room. The group home's workers
didn't know the resident was gone until the neighbor returned the resident.

But the group home never heard back from the agency - allowing the
neglectful employee to work two more weeks with residents before resigning.

The incident in St. Joseph came to light after federal inspectors saw the
report and wondered why it hadn't been investigated. But unlike state-run
institutions, only a handful of private facilities are large enough or
specialized enough to require federal inspections.

And a group that normally monitors the system is also stretched thin. While
it supports the use of private facilities over state ones, Missouri
Protection & Advocacy acknowledges it's much harder for the nonprofit group
to keep tabs on hundreds of group homes spread throughout the state.

Legislators for a decade funded a program with five full-time department
workers who trained and sent volunteers from home to home to check on
residents, but the $195,000 funding was cut last year.

The department is starting a new program this year to send volunteers out.

The new program has a part-time coordinator, with a budget of $22,000.

No punishment

At times the Department of Mental Health has determined workers were guilty
of mistreatment, but the workers have escaped punishment and commited abuse
again.

The department is supposed to immediately put the names of banned workers
on a list that public or private facilities check before hiring a new
employee. But state auditors last year found 38 people on the list who were
working with residents in private facilities. The state's delays in adding
names to the list and delays in finishing investigations were blamed.

One worker at a private facility physically and verbally abused a client,
and it took the St. Louis regional center nearly two years to add the
worker's name to the list. By then, the worker had been hired by another
facility, where the worker verbally abused and neglected another resident.

Auditors also found that the state wasn't ensuring private facilities did
background checks; one place hired someone without performing a background
check and later discovered the new worker had sexually abused a resident
there.

Another facility learned after hiring someone that the worker had
convictions for robbery, unlawful use of a weapon and drug trafficking -
all crimes that disqualify someone from working with mentally disabled
people. The employee was eventually fired, but not before being accused of
sexually abusing a resident.

Mental health officials say they now run regular reports to ensure
background checks are done and banned employees are quickly put on the
disqualification lists.

But there was at least one time Mental Health Department officials knew of
a banned worker, and gave him a license to operate a Kansas City-area home,
Schwab Residential Center II.

Department investigators had substantiated 11 cases of mistreatment at the
home from 1999 to 2004, including one that led to a resident's death. Yet
Mental Health Department officials told state auditors they lacked the
authority to revoke the home's license.

After state auditors raised concerns, the state revoked the home's license.
It became the first facility since at least 2000 to have a license revoked
for abuse or neglect.

Dorn Schuffman, director of the Department of Mental Health, said the
department has shut down other homes with chronic mistreatment of clients,
but it was done under "no fault" provisions of contracts that allow the
state to cancel them for no reason. He won't name the facilities, he said,
because he fears lawsuits if he publicly linked them to mistreatment.

A Post-Dispatch review of licensing and certification files revealed that
mental health officials didn't shut down any other facilities because of
deaths blamed on serious neglect of workers. The state did shut down Turtle
Creek, but only because it had revoked licenses for a group of facilities
of its parent corporation. Oheim's death wasn't listed as a reason.

Mental health officials say they punish facilities in other ways, such as
forcing them to adopt plans to correct their bad behavior. And while
facility operators complain the punishment can be too harsh, department
workers complain the opposite, Woodward said.

"Regional centers will tell you that they have next to no control
whatsoever of the (private) providers, and it's really hard to shut them
down when we need to,"
 he told the commission.

Some advocates for the disabled are demanding more accountability. Among
the critics is Gary Stevens, who has cerebral palsy and speaks with the
help of a caregiver.

"I feel like the providers' money should be pulled, and if they don't do
better, their certification should be pulled," said Stevens, who sits on
the Missouri Planning Council for Developmental Disabilities. "If you start
to pull their money, they'll bow down."

Even some operators of private facilities say they would welcome more
oversight and tougher enforcement of the rules to ensure that residents get
the care they deserve.

One such plea came from Wendy Buehler, president of Life Skills, which
oversees residential services for about 350 people in the St. Louis area.
She told the commission in April that it needed to find ways to shut down
bad facilities.

"Historically they have not been held accountable," she said.

"There doesn't seem to be a position from the department, 'This is a good
provider, this isn't.' They have to be pretty bad to get kicked out."

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Tamie Hopp

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