Speaking out for People with
 Intellectual and Developmental Disabilities

Abuse and Neglect Document

VOR's Ongoing Document:
Updated August 13, 2017
This document provides a bibliography of investigative media series, state audits and peer-reviewed research in more than half the states that detail systemic concerns with regard to quality of care in community-based settings for persons with developmental disabilities. Tragedies range from physical, emotional, and financial abuse, neglect and even death. Many of these outcomes are associated with a zest to move to a "community for all" vision people with developmental disabilities without adequately considering the ramifications of separating vulnerable people from specialized care and then doing away with a critical safety net (a/k/a deinstitutionalization). The lessons learned from more than 25 states should cause policymakers and lawmakers to take pause and recognize that a range of needs requires a range of service options.


Federal Audit: DHHS Failed to Investigate Deaths, Suspected Abuse of Disabled Adults - August 10, 2017

The Maine Department of Health and Human Services failed to investigate the deaths of all 133 people with developmental disabilities who died between January 2013 and June 2015 while under the care of community-based providers across the state, and, as a result, failed to report suspicious deaths to law enforcement agencies to determine if crimes had been committed, according to a federal audit released Thursday, August 10, 2017.

Article from the Bangor Daily News: http://bangordailynews.com/2017/08/10/mainefocus/federal-audit-dhhs-failed-to-investigate-deaths-suspected-abuse-of-disabled-adults/

Inspector General's Audit: https://oig.hhs.gov/oas/reports/region1/11600001.pdf


Company that Operates Oklahoma Group Homes for Children and Disabled Has History of Problems

News OK   June 18, 2017

Deaths, as well as allegations of abuse and assault have emanated from group homes operated by Sequoyah Enterprise Inc., a private company that contracts with state agencies to care for some of Oklahoma's most vulnerable residents. Since 2011, two residents have died at Sequoyah's group home for disabled adults in Stillwater, sparking criminal charges and civil litigation. State agencies have terminated two group home contracts with the company in the past five years after a series of compliance issues. However, the Oklahoma Department of Human Services and the Office of Juvenile Affairs continue to contract with the company to operate group homes across the state. Sequoyah provides about $6.1 million in contracted services annually to DHS.

Tracy Messineo, former director of human resources for Sequoyah Enterprises, filed a federal lawsuit against the company in 2015. In her lawsuit, Messineo claimed she was fired after she discovered the company did not require new hires to receive required DHS training and clear background checks before going to work with disabled adults. Some of the employees had to be terminated after their background checks later revealed criminal histories, the lawsuit claimed.



April 2017 - Following three deaths, a U.S. Department of Justice investigation is underway into the decision to transfer Central Virginia Training Center residents to another state facility. Of six individuals transferred from CVTC to Hiram W. Davis Medical Center in Petersburg since October as part of a plan to address a nursing shortage and eventually close the Madison Heights facility, three have died.                                                                                                                                    The Department of Behavioral Health and Developmental Services transferred twins Tyler and Taylor Bryant to Hiram Davis on Jan. 17 despite their mother’s insistence they remain at CVTC, where they had lived for 20 years. Tyler Bryant died March 16 at the age of 23 at Chippenham Hospital in Richmond.
Chicago Tribune series “Suffering in Secret” documents the State of Illinois’ hiding information about abuse and neglect of adults with disabilities living in group homes (CILA’s).
November – December, 2016
This three-part series reveals the under-reporting of the actual number of incidents of abuse and neglect and suspicious deaths in Illinois by state and county officials, and how flawed investigations often covered up the details of these incidents. The series goes on to conclude that in the rush to close institutions, Illinois glossed over serious problems in group homes.
Department of Health and Human Services, Office of the Inspector General’s Report:
July, 2016
The Office of the Inspector General of the Department of Health and Human Services has been performing reviews in several States in response to a congressional request concerning the number of deaths and cases of abuse of developmentally disabled residents of group homes. This request was made in response to media coverage throughout the country on deaths of developmentally disabled individuals involving abuse, neglect, or medical errors.
The objective of this review was to determine whether the Massachusetts Executive Office of Health and Human Services, Office of Medicaid (State agency), complied with Federal waiver and State requirements for reporting and monitoring critical incidents involving developmentally disabled Medicaid beneficiaries residing in group homes from January 2012 through June 2014.
Department of Health and Human Services, Office of the Inspector General’s Report: Connecticut Did Not Comply with Federal and State Requirement for Critical Incidents Involving Developmentally Disabled Medicaid Beneficiaries                                                      May, 2016
A 2012 report issued by the Connecticut Office of Protection and Advocacy for Persons with Disabilities triggered an investigation of incident reporting of HCBS waiver beneficiaries residing in Connecticut group homes. The Inspector General of the Department of Health and Human Services conducted the audit, reviewing 347 emergency room claims for 245 beneficiaries aged 18 through 59 residing in group homes. They had 310 hospital emergency room visits and were diagnosed with at least 1 of 40 conditions that were similar to many of the causes of death identified in OPA’s 2012 report.


From The VOR Archives: Reports on DD Act Abuse

The Human Consequences of DD Act Abuses: State Specific Reports

The primary programs authorized by the Developmental Disabilities Assistance and Bill of Rights Act (DD Act) are the state Developmental Disabilities Councils (DD Councils), state Protection and Advocacy (P&A) systems, and state University Centers for Excellence in Developmental Disabilities (UCEDD).

Some DD Act programs pursue activities which violate Congressional intent, including activities which:

1. Disregard family input, in violation of the Act's requirement that individuals and families be the "Primary Decisionmakers" through litigation, legislative advocacy, and organizational priorities;

2. Facility closure activities (ICFs/MR deinstitutionalization); and

3. Activities which discriminate against people with severe and profound intellectual and developmental disabilities, and the impact of these activities on these people.

A report of DD Act abuses covering many states is available here.

State Specific reports are available as follows:

The DD Act: The Need For Immediate Reform

For the first time in nearly a decade, Congress will be considering the reauthorization of programs receiving federal funding under the Developmental Disabilities Assistance and Bill of Rights Act (DD Act). 

While the DD Act’s policy endorses residential choice and individual decisionmaking, some DD Act programs, through legislative lobbying, class action lawsuits and other tactics, act to eliminate one of those choices – Medicaid-certified and funded Intermediate Care Facilities for Persons with Mental Retardation (ICFs/MR).