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When it comes to investigating abuse of the developmentally disabled, it all appears to go around and around

November 25, 2019 2 comments

Charles Dickens named his ultimate bureaucratic agency the Circumlocution Office because the public’s business just got passed around in circles in the department.

At least some of that appears to be going on among state agencies when it comes to investigating abuse of persons with developmental disabilities in Massachusetts, according to a review of public records of three state agencies by COFAR.

It appears to be the case with all forms of abuse that the referral and investigation process starts and ends with the Department of Developmental Services (DDS).

In fact, one of the agencies involved – the Executive Office of Elder Affairs (EOEA) –  referred 25 years ago to the process of investigating abuse involving DDS and Department of Mental Health clients as “circuitous,” and stated that attempts to change it through legislation had not been successful in the previous two years. That memo, which we recently received from EOEA, was written in 1994.

COFAR requested and reviewed data and other information on investigations from DDS, the Disabled Persons Protection Commission (DPPC), and EOEA of financial and other types of abuse. We requested the information from each agency under the state’s Public Records Law.

How the circular process appears to work

The circularity appears to start with the fact that DDS is required by state regulations to report all abuse allegations to DPPC, the state’s only independent agency for investigating abuse of disabled adults. But DPPC lacks jurisdiction to investigate financial abuse, in particular, according to the agency’s assistant general counsel, so it refers those cases back to DDS to investigate.

DPPC also lacks jurisdiction to investigate abuse of the elderly, so it refers allegations of all types of abuse involving persons over the age of 59 to EOEA. But EOEA then also refers those same allegations to DDS to investigate if they involve persons living in DDS facilities, according to EOEA officials we talked to and to the 25-year-old memo.

In the May 6, 1994 memo, then Secretary of Elder Affairs Franklin Olivierre stated that under a then newly effective policy, EOEA would send all abuse allegations referred to it from DPPC to EOEA’s “protective service agencies” for investigation. However, if an allegation involved anyone living in either a DDS or DMH-funded residence, the protective service agencies were advised to contact either DDS or DMH, and, in either case, to “screen out” the allegation, meaning not to investigate it themselves.

“Although both Elder Affairs and DPPC recognize that this system is circuitous, attempts to change the statute through legislation have not been successful in the past two years,” Olivierre wrote.

A bill filed by DPPC at that time would have allowed the DPPC to investigate all reports of abuse of persons in DDS and DMH facilities. That bill never passed, and the circuitous referral process continues to exist to this day.

In other words, while abuse of the developmentally disabled largely occurs in DDS-funded facilities, it is DDS that ultimately ends up investigating most of the cases.

Our diagram below depicts the circular flow of referrals of abuse allegations involving victims with developmental disabilities, according to the records we reviewed.

Abuse referrak flow chart3

Beyond the apparent conflict of interest that DDS has in investigating fraud in its own funded and managed programs, it isn’t clear that DDS has the resources to adequately investigate those cases and all of the other forms of abuse that get referred to it.

No centralized record keeping or tracking

It’s not easy to track the circularity of the abuse referral and investigation process because there appears to be no central record keeping or tracking system for abuse complaints and investigations, whether financial or other forms of abuse. Each agency keeps some of the records regarding the abuse investigation process, but no agency appears to have them all.

For instance, while DDS, as noted, is required to refer all abuse allegations it receives to  DPPC, that latter agency tracks the outcomes of investigations only of those allegations that fall under its jurisdiction.

If DPPC receives an allegation of abuse involving a victim with an intellectual disability 60 years old or older, or receives any allegation involving financial abuse, the agency keeps records of the referral of those cases, but not the outcomes.

DDS has two investigative divisions, only one of which even keeps records on the number of abuse allegations reported to it or referred by it to DPPC, according to a response we received from DDS to a Public Records Request.

EOEA, meanwhile, has no records on the number of abuse allegations it receives involving people with intellectual or developmental disabilities, according to a response from an official in that agency regarding a Public Records Request.

Also, EOEA only began keeping records on the number of abuse cases referred to it by DPPC in Fiscal 2018. Similarly, EOEA only began keeping records in Fiscal 2018 on the number of cases it refers to DDS.

DDS, for its part, said it has no records on cases referred to it by EOEA. 

Tracking financial abuse referrals

Within DDS, it appears there are two separate divisions or units that are concerned with  abuse issues – the Investigation Division, which was established in 1993, and the Bureau of Program Integrity (BPI), which was established in 2018.

According to DDS records, the Investigation Division has a staff of 33, including 26 full-time staff investigators.

The DDS BPI only has 3 people on its staff — a director of internal controls, a senior manager, and a risk analyst. The purpose of the BPI is to support the Investigation Division in its financial abuse investigations, develop internal control procedures for DDS, manage a “DDS Theft and Fraud Hotline,” and related matters.

In response to a Public Records Request that we filed specifically seeking data on financial abuse from Fiscal 2016 to the present, DDS informed us that the department does not keep records on the number of financial abuse allegations received by the Investigation Division. The reason given was that all of those allegations must be reported to the DPPC.

However, DDS does apparently keep those records regarding the BPI. DDS stated that the BPI, which is also required to report all allegations to DPPC, received 62 complaints of financial fraud either directly or via its Fraud Hotline since the BPI was established in Fiscal 2018.

DDS did not explain that apparent inconsistency in record-keeping between the Investigation Division and the BPI.

According to DPPC’s own records, from Fiscal 2016 through 2019, DPPC received 1,172 allegations of financial abuse involving DDS clients. It appears that many, if not most, of those allegations were referred to DPPC either by DDS, DDS-funded facilities, the DDS Investigation Division, or the BPI (after the start of Fiscal 2018).

Between Fiscal 2016 and 2019, DPPC, due to its lack of jurisdiction, reported that it referred 895, or 76%, of those 1,172 financial abuse allegations back to DDS to investigate. DPPC also referred an additional 261, or 22%, of the financial abuse allegations it received to EOEA.

EOEA then appears to have referred those 261 allegations back to DDS as well, although we were not able to verify that number through any of the three agencies’ records.

In any case, it would appear that in cases of financial abuse of elderly persons in DDS facilities, those cases are first routinely referred by DDS to DPPC, which then refers them to EOEA, which then refers them back to DDS.

Text for abuse referral blog post6

Low level of completed financial abuse investigations

Although DDS did not have records on the number of allegations referred to or received by the Investigation Division, DDS did state that the Division “completed” a total of 96 investigations of allegations of “financial misconduct” referred by DPPC to DDS from Fiscal Year 2016 to the date of COFAR’s Public Records Request in September 2019.

It was not clear why DDS would have records of the number of referred investigations that the Investigation Division completed, but would not have records of the number of cases referred by DPPC to the Investigation Division. Given the staffing of each of the two DDS investigative divisions, it would appear that the Investigation Division would or should have investigated most, if not all, of the 895 referrals.

If the DDS Investigation Division completed a total of only 96 out of 895 financial fraud investigations referred to it by DPPC in that 4-year period, that would amount to a completion rate of only about 11% of the cases. DDS substantiated a total of 12 of those 96 allegations.

EOEA and DPPC records may not line up 

Of the 1,172 financial abuse allegations it received from Fiscal 2016 through 2019, DPPC referred 261 of them, as noted, to EOEA, according to DPPC’s response to our Public Records Request. Given that those cases all involved DDS clients, it would appear that EOEA, according to its 25-year-old policy, would or should have referred all of those cases to DDS.

It was actually not possible for us to verify, based on DDS and EOEA records, that all of those 261 cases referred by DPPC to EOEA were, in fact, subsequently referred by EOEA to DDS.

As noted, DDS said it has no records of the number of abuse cases referred to it by EOEA. EOEA, as noted, only began tracking the number of cases referred to DDS in Fiscal 2018.

In fact, DPPC’s and EOEA’s records don’t appear to line up in that respect. EOEA responded to us that in Fiscal 2018, it referred zero abuse cases to DDS. However, according to DPPC’s records, DPPC referred 42 allegations of financial abuse involving DDS clients to EOEA in Fiscal 2018. According to EOEA’s policy, it should have referred those 42 cases to DDS that year.

The solution to the circular referral process lies with DPPC

Our recommended solution to the overall referral and investigation problem is to revive and enact the legislation that DPPC proposed 25 years ago.  DPPC should have the resources and authority needed to investigate all forms of abuse of the developmentally disabled, including persons over 60 years of age.

Right now, the investigative process involving abuse and neglect of persons with developmental disabilities is split among at least three agencies. It is a circuitous system rife with potential conflicts of interest and one in which record-keeping and apparently cooperation in undertaking investigations among the agencies is dispersed and spotty.

We plan to share these findings and our recommendation with the Legislature’s Children, Families, and Persons with Disabilities Committee. The current abuse investigation and referral system appears to be set up for failure and needs to be reformed.

 

A recap of our cases of abuse and neglect in the DDS system

November 18, 2019 7 comments

We receive calls on a regular basis from family members and guardians of persons in the Department of Developmental Services system who are dealing with, abuse, neglect, poor care, and related issues.

We always try to help where we can by offering advice and working with the Department of Developmental Services and other agencies and organizations to rectify the situations, and, in some cases, informing the public about the matters through our blogsite and newsletter.

Below are summaries of some of the major cases that have appeared on this blogsite in recent years. We’re happy to say that at least some of these cases were ultimately resolved favorably for the individuals, families, and guardians involved; but these cases are all disturbing signs of a broken system.

Most, though not all, of the cases brought to our attention have involved incidents that occurred in group homes or day programs operated by corporate providers under contract to DDS. We occasionally get calls about incidents in state-operated group homes, and some of those cases are summarized below. In many instances, however, problems were ultimately solved when victims or other clients involved were transferred from provider-run to state-run facilities.

That’s one reason we have advocated for so long for the preservation of state-operated group homes and the two remaining DDS-run developmental centers. It has been our experience that the rapidly expanding privatization of residential and other DDS services has created a race to the bottom in terms of care and services — a system in which abuse and neglect are rampant.

Every year, as state funding for the provider-run residential line item has risen, the number of abuse complaints received by the Disabled Persons Protection Commission (DPPC) has risen as well. In many cases, the DPPC and other agencies lack resources to adequately investigate these complaints. That is reflected in the individual stories that we hear when people call us.

In one of the cases we’ve included below, a young woman endured poor and in some cases life-threatening care in a series of provider-run facilities and a state-operated residence until she was finally admitted to the Wrentham Developmental Center where the family described her care as “exquisite.” That’s because the state-run developmental centers must meet strict federal standards for care that are waived for facilities in the “community-based” system.

There are other cases recounted below in which family members and sometimes guardians have been subjected to intimidation and retaliation by providers and by DDS after they raised concerns about poor care.  There are even cases in which families and guardians have been barred from entering their loved ones’ group homes or even prohibited from all contact with those family members — situations, which we have argued violated DDS regulations.

Mixed record of official concern

We have continued to raise these concerns with DDS, the DPPC, a variety of other legal enforcement agencies, the media, and advocacy organizations, and with key legislators.

Last year, after one particularly egregious case, recounted below, in which a young man nearly died in a group home after aspirating on a piece of cake, the Legislature’s Children, Families, and Persons with Disabilities Committee, did hold two informational hearings on abuse and neglect in the DDS system. But we have heard of no follow-up on those hearings by the committee.

In another case in which a provider apparently failed to take a resident of a group home for either doctor’s or dentist’s appointments for seven years, the provider acknowledged failures in its protocols and took corrective actions after COFAR brought the case to the public’s attention. In addition, DDS opened an investigation of the provider.

We have continued to ask the Children and Families Committee to approve H.93, a bill that would improve transparency in the DDS system about abuse and neglect. The bill would require DDS to post easily understandable, comparative information on its website about abuse and neglect and provider performance.

One of the cases below, involving the death of Karen McGowen, highlights the lack of transparency in abuse and neglect investigations done by the DPPC, in particular. The agency refused to release any investigative records in the case, and, as we have reported, is trying to further ensure the secrecy of its records.

In the cases summarized below, the families and guardians agreed to go public. Not included are many cases in which we have and continue to advocate on behalf of families and guardians who asked us not to reveal the details of their cases publicly.

Timothy Cheeks: Center for Human Development group home, East Longmeadow, staff neglect

(More information here)

In 2018, Mary Phaneuf, the foster mother of Timothy Cheeks, began raising concerns  about Tim’s care in a group home operated by the Center for Human Development (CHD) in East Longmeadow.

Mary’s concerns included a lack of proper medical care for Tim, 41, and no documented visits to a primary care physician or dentist for seven years. Mary also said there were no documented visits to a cardiologist for six years despite Tim’s having been born with a congenital heart defect.

After COFAR contacted CHD about the matter, the provider’s CEO and president acknoweldged “failures to follow protocols,” among other problems and said the organization was taking a range of corrective actions.  In an August 2019 statement provided to COFAR, DDS Commissioner Jane Ryder said that DDS was investigating the allegations and was requiring the Springfield-based provider to implement a corrective action plan.

Despite the seriousness of the issues that Mary raised, an online June 2017 DDS licensure inspection report for CHD did not mention those or similar problems of neglect in CHD’s group homes.

Tommy Shea: Staffed apartment, staff neglect

(More information here)

Maureen Shea’s son, Tommy,  who was 33, had an intellectual disability and was subject to epileptic seizures while asleep.

Tommy’s bedroom in his staffed apartment was equipped with an audio and visual monitor that could alert the staff so that the staff could make sure that during a seizure he didn’t roll over face-down — a position that can prevent breathing.

Maureen and her daughters were nevertheless concerned that the residential staff did not regularly check the monitor’s batteries and that they had not been adequately trained in how to position the device. But provider managers had repeatedly assured Maureen that the staff were being trained and were knowledgeable about Tommy’s medical equipment.

Tommy had just returned on June 7, 2017, from a two-week stay in a hospital to his apartment. The following day, Maureen received a call from the residential supervisor to come to the residence immediately. When she arrived, the police were there. They told her that Tommy had died and that he had been found face-down on his bed. The batteries in the monitor were later found to be dead.

Maureen is pushing for S.73, a bill, which specifies that when a disabled individual is discharged from a hospital to a residential group home, a licensed medical professional from the group home must review and acknowledge the full requirements of the hospital discharge plan with respect to life support equipment. The medical professional must then advise the group home staff about those requirements.

Family separation case, isolation, family intimidation

( More information here)

In November 2015, a DDS guardian imposed a three-year ban on family contact with a developmentally disabled woman, and specifically prevented David and Ashley Barr, the woman’s father and sister, from visiting her.

The woman has been diagnosed with an intellectual disability and mental illness.

The guardian never clearly explained the reason for her family separation policy, which was nevertheless been upheld by DDS.  For the next three years, the guardian prohibited all members of the family other than an aunt from having any contact with the woman, and would not even inform the family as to where she was living. We have withheld the woman’s name because she was a victim of sexual assault.

In November 2018 email to Ashley, the guardian stated that she was finally granting permission to Ashley and David to visit the 30-year-old woman for the first time since November 2015.

In her email, the guardian wrote that she would now allow visits because the woman’s mother, Nancy Barr, had been sentenced in a criminal case involving the sexual assault of the disabled woman by Nancy Barr’s boyfriend, John Leone. Nancy and David Barr have been divorced since 2003. No members of the family other than the woman’s mother were involved in the abuse or were ever charged in the case.

Karen McGowen: Unexplained death, day program, provider unknown, records kept secret

(More information here)

Karen McGowen, a DDS client, was killed in an apparent accident in November 2017. She reportedly fell from a wheelchair lift while getting out of a van at her Pittsfield-based day program funded by DDS.

The DPPC, which is charged with investigating or supervising investigations of abuse and neglect of disabled adults under the age of 60, confirmed it was investigating Karen McGowen’s death. The DPPC denied all requests from COFAR for the records in the case.

Holly Harrison: TILL, Inc. group home, Danvers, staff neglect and poor care, family intimidation

(More information here)

Despite a state regulation that gives residents of state-funded facilities the right to be visited, a human services provider agency upheld a directive barring a guardian of a developmentally disabled woman from entering her group home.

The August 2017 directive from the provider, Toward Independent Living and Learning, Inc. (TILL), stated in writing that the guardian, Susan Fernstrom, “will not go into the residence” even to bring food or other items to her daughter, Holly Harrison.

It appeared that the only reason for TILL’s prohibition against Susan from entering the home and for a subsequent notice of eviction of Holly was that Susan had pointed out deficiencies in the staff’s compliance with Holly’s medically necessary dietary restrictions on a number of occasions. Susan had also complained about conditions in the residence.

In addition to having an intellectual disability, Holly has a serious genetic metabolic condition called galactosemia, which requires a diet free of galactose, a form of sugar found in milk and cheese. That diet must be strictly adhered to in order to avoid complications including brain and kidney damage. Holly must also eat multiple servings of vegetables because she does not metabolize all the nutrients in her food.

Susan had in the past raised concerns that the group home staff was not following her instructions either in buying food for Holly or preparing and serving it to her. Her complaints appear to have led directly to the issuance of the directive banning her from the residence.

David Buckley: DDS group home, West Peabody, staff physical abuse;  provider-based group home, Hamilton, staff sexual abuse

(More information here)

On the morning of March 30, 2001, David Buckley, received second and third degree burns to his buttocks, legs, and genital area while being showered by staff in a West Peabody-based group home run by DDS. The temperature of the water in the residence was later measured at over 160 degrees.

David died from complications from the burns 12 days later, yet no one was ever charged criminally in the case, and the DDS (then Department of Mental Retardation) report on the incident almost unbelievably did not substantiate any allegations of abuse or neglect.

Before that shower incident, David had endured a series of incidents of alleged abuse and neglect in a provider-run group home in Hamilton, including an alleged sexual assault by a caregiver. That incident had been witnessed by another staff member of the home. Yet, the witness failed to report the alleged abuse for two weeks, and, as a result, no one was ever criminally charged in that case either.  

Alexa Horn: Multiple residences, abuse neglect. Care at Wrentham Center deemed “exquisite.”

(More information here)

Alexa Horn , who has Rett Syndrome, a neurological disorder, had lived at home until she was 16. At that time, her parents, Pat and Michael, explored the possibility of getting Alexa into the Fernald Developmental Center, but they were told Fernald was closing.

Pat said she and Michael found a special needs residence for Alexa, but she developed a urinary tract infection and a subsequent sepsis infection there. The infections occurred after direct-care staff failed to tell the facility’s nursing staff that Alexa had not eaten or drunk anything for almost 24 hours.  Alexa was cared for in the intensive care unit at Boston Children’s Hospital for two weeks and was transferred to Franciscan Children’s Hospital for six weeks of rehabilitation.

When she turned 22, Alexa was placed in a DDS-funded group home near her family home in Watertown in which the care was quite good for a number of years. After five years, however, the residence started to experience a high degree of turnover of house managers, and new direct care staff were hired with little apparent training or qualifications.

Pat said the residence became dirty, clinician appointments were missed, protocols for administering Alexa’s medications and her feeding tube were not followed, and her personal hygiene degraded to the point that she had to be treated for ringworm, a type of fungal infection of the skin, on numerous occasions.

In 2014, Alexa fell out of her shower chair while a staff member was showering her because the staff member had undone her safety belt in order to wash her back. Her injuries required a trip to the emergency room and an MRI. Miraculously, Alexa did not sustain any serious injury in that incident, but she did suffer a significant amount of soft tissue damage to her face and broken blood vessels in her eye.

In another incident, the same caregiver failed to check the rate of the feeding pump when setting up her g-tube feed, and Alexa received 12 hours worth of food in a two-hour period, causing her to vomit and aspirate.

Early 2015, Pat said, she was informed by staff during a weekly Saturday visit that Alexa’s leg had been hurting her since the beginning of that week, but that the house manager had not taken her to be assessed by her doctor. The Horns called the manager on duty that weekend, who finally took Alexa to a hospital emergency room where an x-ray confirmed that Alexa had a fracture of the tibia.

The Horns then arranged to have Alexa sent to the Marquardt skilled nursing facility on the grounds of the then closed Fernald Center rather than to have her discharged back to the group home.

During her first months at the Marquardt, as she was recovering from her broken arm, Alexa contracted pneumonia and respiratory failure. After two weeks on a respirator at Mt. Auburn Hospital, she was transferred to a rehabilitation hospital where she contracted a ventilator-acquired pneumonia and a gastrointestinal infection, and suffered from serious seizures because of the medications given to combat the infection. After two and half months, she was finally well enough to be transferred back to Marquardt.

In August of 2016, the Horns learned that the Marquardt center was going to be closed, and Alexa finally became a resident of  the Wrentham Developmental Center in February of 2017. They termed the care at Wrentham “exquisite.”

Ryan Tilly: NEEDS Center, Inc., abuse and neglect, family intimidation, group home in Haverhill

(More information here)

Ryan Tilly, who has Down Syndrome, had been living in his provider-operated group home in Haverhill for only four months in March of 2016 when he was allegedly assaulted by a staff member of the residence.

The Tillys maintain that in addition to the assault, Ryan was subjected to neglect in the group home, which is operated by the NEEDS Center, a DDS provider.  He was also harassed by another resident of the group home so severely in 2016 that he continued to isolate himself in his room there and was afraid for a period of time to take showers in the residence.

Rather than working with the family to address those problems, both NEEDS and DDS initially turned against the parents, according to the Tillys and to documents in the case. The Tillys were accused of being “volatile and unpredictable,” and of fabricating a charge that the staff was failing to clean clothing that Ryan had soiled.

Ryan’s father, Brian, was banned for months from visiting Ryan in the NEEDS residence, while Deborah had to make appointments in order be able to see him.

A DDS investigation of the Tillys’ allegations regarding Ryan’s clothing determined that there wasn’t sufficient evidence to charge the group home with neglect in the matter; but the report did not refute the allegations.

In September 2016, DDS recommended that NEEDS and DDS meet regularly with the Tillys to “foster cooperation,” and that DDS explore possible new residential options for Ryan. But neither NEEDS nor DDS appear to have fostered that communication, at least initially. The restrictions against the Tillys on visiting Ryan in the group home continued through at least October of 2016, according to emails from the provider.

Yianni Baglaneas: Bass River, Inc., neglect, cover-up, group home in Peabody

(More information here)

In April 2017, the staff of a group home in Peabody failed to react for nearly a week after Yianni Baglaneas, 29, reportedly aspirated on a piece of birthday cake in the residence. Yianni was admitted to Addison Gilbert Hospital in Gloucester in critical condition, and spent 11 days on a ventilator and a week in the Intensive Care Unit at Mass. General Hospital.

According to a DPPC report on the incident, the residential director of the group home acknowledged instructing staff of  the residence not to cooperate with the DDS investigation into the matter. The director also acknowledged removing records from the facility.  The DDS investigator was subsequently unable to locate key records relating to Yianni’s care.

The DDS report stated that charges of abuse and mistreatment were substantiated in the case against seven employees of the provider, Bass River, Inc. The report found that the group home staff was negligent in failing to ensure that Yianni, who has Down Syndrome, regularly used a portable breathing mask at night called a CPAP (continuous positive airway pressure) machine. Based on the input of a medical expert, the report concluded that the failure to use the machine was the cause of the aspiration that led to Yianni’s near-fatal respiratory failure.

Andy McDonald: Family intimidation

(More information at here)

DDS has ignored requests by the parents of Andy McDonald for a new clinical evaluation of  Andy, who was deemed too dangerous in 2006 ever to be allowed to visit his family home in Sherborn.

Since Stan and his former wife voluntarily relinquished their guardianship of Andy in 1986 as part of a custody battle, Andy, who is intellectually disabled, has lived under a series of court-appointed guardians.  Like many people who lose or fail early on to secure guardianship of developmentally disabled members of their families, Stan and his current wife, Ellen, have been repeatedly stymied in their efforts to obtain that guardianship.

Stan and Ellen are rarely even informed about major events or issues regarding Andy’s guardianship; and the Middlesex County Probate Court failed for six months in 2016 to appoint an attorney to represent Andy, as required by law.

COFAR is supporting a bill (H.1415), which was first filed in 1999 on behalf of the McDonalds. The bill would require probate court judges to presume that the parents of developmentally disabled persons, or third parties designated by the parents, are suitable as guardians for those individuals. Despite no known public opposition, the bill has never been approved by the Judiciary Committee.

 Anthony Remillard: Templeton Developmental Center; and Brett Reich, Lifeworks, group home in Attleboro, neglect and lack of supervision by DDS and the provider

(More information here)

Brett Reich and Anthony Remillard are both men with intellectual disabilities, and both either served prison time or were faced with prison time for committing assaults. In each case, DDS appears to have failed to provide adequate supervision and treatment for them.

Unidentified man, Lowell General Hospital, neglect, lack of training

(More information here  and here)

A 2012 report by the state Department of Public Health exonerated Lowell General Hospital in the case of an intellectually disabled man who died of an apparent heart attack in 2012 after having been sent home twice by the hospital without any significant treatment.

The DPH report confirmed that the 51-year-old patient was discharged twice from the hospital in two days, and was pronounced dead after he was brought back to the hospital for the third time.

Despite the exoneration, the report appeared to leave many questions about this case unanswered — particularly whether the man, whose identity has been withheld, may have received inadequate care because hospital staff was not properly trained in dealing with developmentally disabled people.

This was one of three cases that were brought to COFAR’s attention in 2011 and 2012 in which DDS clients, each of whom happened to be a man in his 50’s, died suddenly after being transferred from developmental centers to state-run group homes operated by Northeast Residential Services, a division of DDS.

A second case was that of a former resident of the Fernald Developmental Center, who died on July 6, 2011, after having ingested a plastic bag in a Northeast Residential Services group home in which he was living in Tyngsborough.  In that case, a DPPC report concluded that there was a lack of adequate supervision of the man by his caregivers, although the investigative agency was unable to determine whether the man had ingested the plastic bag while he was in the group home or his day program or was being transported between the two.

In a third case, a former Templeton Center resident died on July 24, 2011, four days after he was transferred to a state-operated group home in Tewksbury.  The cause of death was reportedly a blood clot in his lung.

Paul Stanizzi: DDS Northeast Residential Services group home in Chelmsford, abuse; previously, Edinburg Center group home in Bedford, neglect and possible abuse

(For more information here  and here)

In February 2019, two staff members of a DDS group home were arrested for allegedly hitting and slapping Paul Stanizzi, a 50-year-old intellectually disabled man who is non-verbal.  This was the second residential facility in which Paul was allegedly injured or assaulted by staff.

In June 2014, the DPPC substantiated charges of abuse and neglect against a staff worker in a Bedford, provider-run group home in which Paul was seriously injured the previous August. Paul was at least partially paralyzed in that incident in that residence, which is operated by The Edinburg Center, Inc.  According to a DPPC report on the incident, Paul was found lying on his back in his room by the staff worker on the morning of August 27.

The staff worker, who had been on the overnight shift, told investigators he had heard noises in Paul’s room during the night, but never investigated them and then fell asleep for several hours during his shift.

Paul, who is non-verbal, was taken to Lahey Clinic in Burlington, which determined he had a spinal injury.  No group home staff accompanied Paul to the hospital, according to the report.

Sara Duzan: Becket Family of Services, Inc. group home in Westminster, abuse, neglect, family intimidation

(More information here)

In 2013, a DDS guardian issued an order forbidding the family of Sara Duzan, a woman with an intellectual disability from all communication with her.

Members of the Duzan family said they were concerned that Sara was been subjected to abusive physical restraints and seclusion at the Becket residence, but that they had had no way of knowing what Sara’s care and living conditions really were.

Sara, then 21, has a rare genetic disorder called Smith Magenis Syndrome, which is characterized by intellectual disability and behavioral outbursts. The Duzans lost their guardianship of Sara in 2009, stemming from both an admission by Sara’s mother, Maryann, that she once lightly slapped her daughter on the cheek, and the conclusion of a probate judge in 2010 that while the family had never abused Sara, they had been uncooperative with providers in caring for her.

John Burns: Center for Human Development, Alleged Abuse

(More information here)

In August 2012, a jury acquitted a staff member of a group home operated by the Center for Human Development (CHD) in Springfield of allegedly assaulting John Burns, a man with an intellectual disability, during an outing on Cape Cod for clients of the home.

Sheila Paquette, of Westfield, Burns’ sister and guardian, ultimately filed the assault charge against the staff member herself in July 2010 when she became convinced no law enforcement agencies were going to do so.

It was only after Paquette filed the charge that the DPPC sent a state trooper to her house to investigate, she said. Despite that, the case languished for months at a time, beset by bureaucratic snafus and witness no-shows that caused the trial to be postponed four times.

When the trial finally took place, the District Attorney’s prosecution effort seemed half-hearted. Among other questions COFAR had about the case was why no one from the DPPC or its state police unit was called to testify at the trial.

The DPPC had issued a comprehensive report on the incident in February 2011, which did find sufficient evidence to conclude that Burns was “seriously injured” by the caregiver.

Tholda Chhom: Northeast Residential Services, Chelmsford, lack of supervision

(More information here)

In June 2011, a resident of a state-run group home in Chelmsford walked out of his residence, went next door and attacked a pregnant woman as she was sitting in her living room with her husband and three-year-old daughter.  The man managed to tear off Amy Hillman’s shirt and jump on top of her before he  was pulled away by Hillman’s husband, James.

The group home resident, Tholda Chhom, and James Hillman ended up in the front yard, where Chhom continued to charge at Hillman before running back to his residence just before police arrived, according to witnesses.  Chhom was later charged with assault and attempted rape, and was then placed in a “more secure state facility,”  according to The Lowell Sun.

COFAR is concerned that this case shows that even state-run community residences lack an intensive care model that meets the federal standards set for Intermediate Care Facilities.  ICF-level care, which exists only in two remaining developmental centers in Massachusetts – the Wrentham and Hogan Centers — stipulates that residents receive onsite clinical, medical, and nursing care and full-time supervision.  Not everyone with intellectual disabilities needs this level of care.  Only a small fraction of them do.  But Chhom would appear to be one of them.