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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.

Should we require video cameras in DDS group homes?

October 23, 2019 6 comments

A bill filed in the state Legislature would require residential programs across the state for persons with developmental disabilities or mental illness to install video surveillance cameras in common areas in their facilities in order to deter and potentially prosecute abuse.

We support the bill (H.158) in concept although we’re not sure how effective the measure, as currently drafted, would be because it would not require security cameras in bedrooms. The bill is in the Children, Families, and Persons with Disabilities Committee. We’ve posed a number of questions to the committee about it.

H.158 states that video cameras must be installed at all entrances, exits, and common areas of facilities licensed by the Departments of Developmental Services and Mental Health, including community-based group homes and inpatient facilities. The bill, however, would not require the installation of cameras in bedrooms, where it could be argued that most abuse occurs.

If properly drafted, this bill could serve as an additional safeguard to abuse and neglect, and supplement a separate bill (S. 2367), which would establish a registry in the state of caregivers found to have abused persons in DDS-funded facilities. S.2367, known as Nicky’s Law, was approved unanimously by the Massachusetts Senate last week.

Massachusetts currently appears to have no laws that specifically restrict videotaping in group homes, but there are statutes and regulations that restrict audio-taping without consent. A guardian can apparently install a video and audio camera in the bedroom of a developmentally disabled individual with the permission of the facility provider.

On October 15, I emailed a number of questions relating to H.158 to the Legislature’s Children and Families Committee. Among my questions were:

1. Do you know whether similar legislation has been enacted elsewhere or what its effectiveness has been?

3. Do you have any information or estimates on the cost of installing and maintaining cameras and monitoring units in all DDS and DMH residential facilities?

4. Do you have any information on the number of abuse incidents that occur in common areas or in entrances or exits of group homes?

To date, I have not yet heard back from the Committee.

Literature on video surveillance in group homes and other long-term care settings

There is some academic literature that is critical of the idea of video surveillance in long-term care facilities. But there are experts who vouch for the effectiveness of video surveillance, at least in helping prosecute caregivers for abuse. There seems to be some agreement that the cameras are not necessarily as effective in deterring abuse as in helping prosecutions after abuse has occurred.

Judge Rotenberg Center case

An article by The New England Center for Investigative Reporting (NECIR) implied that cameras were effective in bringing criminal charges in at least one case at the Judge Rotenberg Center in Canton, MA. The October 29, 2018, article stated that a 22-year-old man was repeatedly whipped by a belt-wielding caretaker in a Rotenberg Center group home. The caretaker was criminally charged after his actions were caught on video.

Apparently, the Rotenberg Center and its 45 group homes are equipped with surveillance cameras. At the same time, however, it appears the cameras have apparently not stopped the relatively high number of abuse cases that the Rotenberg Center is cited for each year.

The Rotenberg Center has long been a focus of controversy because of its practice of administering electric skin shocks to program clients as a behavior modification technique.

The NECIR found that the Rotenberg Center was cited for abuse of adult residents more than any other special needs school by the Disabled Persons Protection Commission between 2011 and 2016. Our own analysis of DPPC data showed that the Rotenberg Center led other providers in two separate regions in the state in total complaints or highest percentage of abuse complaints referred for criminal investigation between Fiscal 2010 and 2019.

Rape case spurs camera legislation in Arizona

Palm Beach Post article in February discussed the debate over surveillance cameras in noting that a rape in an an Arizona Intermediate Care Facility was spurring legislation in that state to allow cameras in long-term care facilities.

The article stated that Arizona was considering whether to join 10 other states — Illinois, Kansas, Louisiana, Maryland, New Mexico, Oklahoma, Texas, Utah, Virginia and Washington — with laws or regulations allowing surveillance equipment inside nursing homes, assisted living centers and other group residential settings.

The Palm Beach Post article noted that most of those laws place the option and cost of electronic monitoring on residents and their guardians. According to the article, a majority of the laws allow residents or their surrogates to put cameras or monitoring devices in their rooms but require them to notify the facility, among other conditions.

Carole Herman, founder of the advocacy group Foundation Aiding the Elderly, was quoted in the article as saying, “The (healthcare) industry doesn’t want it obviously. But if they care about these people, what’s the resistance to these cameras?”

The article also quoted one expert who said a properly designed closed-circuit TV system with “multiple monitoring points” could be a good deterrent.  However, in many cases, nobody is watching the video monitors, the expert said.

We think it might make sense to add a requirement to H.158 that DDS-funded facilities install surveillance cameras in bedrooms or other areas where abuse is known to take place, provided that the DDS clients involved or their guardians or family members agree to those placements. As noted, it does not appear to us that current law would prevent those installations.

Ultimately, we think the solution to the abuse problem lies in changing the culture in provider organizations, which is currently lax regarding training and supervision of group home staff. Without first taking that step, relying on surveillance technology and the registry may lead to a false sense of security.

We have questions for a legislative subcommittee reviewing employment of the developmentally disabled

October 8, 2019 25 comments

A special legislative subcommittee’s review of barriers to employment of persons with intellectual and developmental disabilities (I/DD) is long overdue, but it is unclear what direction the subcommittee will take on this important issue.

The “Workability Subcommittee” of the Massachusetts Legislature’s Children, Families, and Persons with Disabilities Committee has scheduled a public hearing on October 22 at 10:30 a.m. at the State House in Room B-1.

The hearing notice states that the Subcommittee is seeking to identify “solutions to promote opportunities for individuals with disabilities to participate and succeed in the workforce.”

Patty and Mark Garrity photo2

Patty Garrity and her brother Mark. After Mark’s sheltered workshop closed in 2016,  meaningful work activities came to an end for him. Mark is not capable of participating in a mainstream work environment, Patty says.

COFAR and our members plan to testify at the hearing. We haven’t been  consulted by the Subcommittee as part of its review, which began last spring and involved meetings with “disability advocates, employers, employees, and other stakeholders,” according to the hearing notice.

So on October 4, when we heard about the hearing, we posed questions in an email to the office of Representative Josh Cutler, chair of the Subcommittee and vice chair of the Children and Families Committee. Those questions were the following:

  • Does the Subcommittee recognize that there are some persons who do not have the capability to succeed in the mainstream workforce, or does the Subcommittee take the  position that all persons, no matter how profoundly intellectually disabled, can handle jobs in the mainstream workforce?
  • Is the Subcommittee also looking to promote work opportunities for individuals in their community-based day programs funded by the Department of Developmental Services?
  • Does the Subcommittee have data on the availability of mainstream workforce jobs for persons with I/DD? We have long been concerned that not nearly enough of those jobs exist even for those who are capable of doing them.
  • Is the Subcommittee aware that the Legislature has apparently never appropriated the level of funding sought by the Baker administration for training and other services to help prepare former sheltered workshop participants for mainstream work settings? If so, has the funding for that transition so far been adequate?
  • Does the Subcommittee support the continued payment of subminimum wages to persons with I/DD in order to enable them to get work opportunities either in mainstream or DDS settings?

In an email in response to us, Rep. Cutler declined to respond to our questions; but he did say they were “great questions” and that he would be interested in meeting with us. We are in the midst of scheduling a date for that meeting.

We have discussed employment issues involving people with I/DD in numerous blog posts and in legislative testimony since 2014 when the administration of then Governor Deval Patrick began closing sheltered workshops for persons with I/DD throughout the state.

The sheltered workshops were settings in which DDS clients did small assembly jobs and other piecework activities provided by area businesses. The participants usually received a nominal wage.

Many family members and guardians strongly supported the workshops; but the Patrick and then Baker administrations held to an ideology that the workshops “segregated” the participants from non-disabled workers, and that the participants would all be better off in mainstream, “integrated” job settings.

Here are some of our findings from our involvement with these issues over the past five years:

  • Starting in 2013, the Patrick administration worked closely with corporate DDS providers to close the sheltered workshops over the objections of the families of many of the participants. In doing so, the providers falsely claimed that the workshops did not allow for “community inclusion.” The providers also falsely claimed that the federal government was forcing all sheltered workshops to close in the state.
  • As of 2018, it was clear that the promise of the replacement of sheltered workshops in Massachusetts with mainstream integrated employment was not being realized. An unknown number of former sheltered workshop participants were being left without work of any kind in their DDS-funded day programs.
  • The position of Senator Elizabeth Warren and many others against the payment of subminimum wages to people with I/DD has made it even harder for those persons to find the kind of work they had previously enjoyed doing.

Patty Garrity is the sister of one of those former workshop participants who has been left without work opportunities. Her brother Mark is not able to work in a competitive, mainstream setting.

Garrity said she plans to testify at the October 22 Subcommittee hearing. “I want to explain that there are individuals like my brother Mark and his peers who are not minimum wage candidates,” she wrote in an email.  “There is still a huge void in Mark’s day and it is not going well…..going on 4 years now that I have been waiting for them to improve upon this and it is not happening.  Mark is happy to be with his peers, but all he is doing is shredding paper and he is bored.”

We hope the Subcommittee will pay close attention to the experience of Mark Garrity and others who have been left behind in the wake of the sheltered workshop closures.

Moreover we hope the Subcommittee does or will recognize that, as with so many other issues involving persons with I/DD, one size doesn’t fit all when it comes to employment.

There are many people for whom the mainstream, competitive workforce is not suitable. Their choices and the choices of their families and guardians should be respected.

Nearly inaccessible DPPC data illustrates widely varying abuse problem among group home providers

September 19, 2019 8 comments

An analysis by COFAR of data provided by the Disabled Persons Protection Commission (DPPC) confirms what many families of persons with developmental disabilities know from often bitter experience.

That is that providers to the Department of Developmental Services of residential and other services have widely different track records of abuse and neglect.

Unfortunately, families and guardians must learn about those differences almost exclusively by trial and error. There is currently no online source of comparative information about abuse and neglect among providers in Massachusetts.

In our analysis (see chart below), we were able to identify which providers had the highest numbers of complaints lodged against them, the highest numbers and percentages of substantiated complaints, and the highest numbers and percentages of complaints referred for criminal investigation.

(See complete analysis of all of the providers with highest and lowest results here.)

If family members or guardians or members of the general public wanted this information on an ongoing basis, they would have to do what we did. First, we had to file a Public Records Law request with the DPPC for abuse data broken down by region and provider from Fiscal Year 2010 to the present.

Next we had to sort the regional raw data by provider, which the DPPC provided on spreadsheets, and literally count the number of complaints listed for each provider and the number of substantiations and referrals for investigation. It was a lengthy process that took us weeks to complete.

In sum, we tracked the disposition of more than 14,000 complaints lodged against roughly 120 providers, including DDS itself as a provider of residential services in developmental centers and state-operated group homes.

Of the total complaints tracked, an average of 116 were lodged against individual providers between Fiscal 2010 and 2019.

In addition, an average of 8 complaints per provider, or 6.7% of total complaints against providers, were substantiated after investigations supervised by the DPPC.

Finally, an average of 13 complaints per provider, or 11.2% of complaints, were referred to district attorneys offices for criminal investigation.

DPPC provider abuse data summary chart4

State-operated facilities tend to have lower percentages of substantiated abuse

While two state-operated group home networks had the highest number of complaints in the Northeast and Southeast regions respectively, the state-operated residences had below average percentages of complaints substantiated or referred for criminal investigation.

State-run developmental centers were at the bottom of the list in terms of reported abuse. The former Templeton Developmental Center (now state-operated group homes)  had only 25 complaints lodged in the 10-year time frame, and zero complaints substantiated or referred for criminal investigation.

The Wrentham Developmental Center had 71 complaints, but only 1 substantiated and none referred for criminal investigation. The Hogan Regional Center had 28 complaints, 1 substantiated, and 4 referred for criminal investigation.

Proposed legislation would require DDS to provide information online

Late last year, we asked Representative Daniel Cahill to file a bill in the current legislative session that would require DDS to post easily understandable, comparative information on its website about abuse and neglect and provider performance.

The bill (H.93), which is modeled on an online database in the state of Illinois, has been in the Children, Families, and Persons with Disabilities Committee since January.

We are urging people to call the Children and Families Committee at (617) 722-2011 (for Rep. Kay Khan, House chair) and (617) 722-1673 (for Senator Sonia Chang-Diaz, Senate chair), and urge the committee to vote favorably on the bill.

Results broken down by provider and region

In our Public Records request to the DPPC last February, we asked for abuse data broken down by DDS providers from Fiscal Years 2010 to the present. Based on our analysis of that DPPC data, the chart above contains a summary of the providers leading in various measures of abuse in each of five regions of the state.

As reflected in the chart above, among our preliminary findings regarding the DPPC’s data from Fiscal 2010 to 2019 are the following:

  • Vinfen, Inc. had the highest total number of abuse complaints among all providers reviewed in all regions (561). This compares to an average among all of the providers reviewed of 116 complaints.
  • Guidewire, Inc. had the highest number of complaints substantiated (46). This compares to an average among all providers of 8.
  • The Judge Rotenberg Center had the highest number of complaints referred for criminal investigation (80) and the highest percentage of total complaints referred for criminal investigation in a single region (31.82%).
  • The Judge Rotenberg Center led in two separate regions in total complaints or highest percentage of complaints referred for criminal investigation.

The Judge Rotenberg Center has long been a focus of controversy because of its practice of administering electric skin shocks to program clients as a behavior modification technique.

  • The May Institute led in two regions in most complaints substantiated or highest percent substantiated.
  • Community Resources for Justice led in one region in total complaints, total substantiated, and highest number referred for criminal prosecution, and in a second region in highest percent substantiated.

Need for investigation

We’ve sent our findings to the Attorney General’s Office, and intend to provide them to the Inspector General’s Bureau of Program Integrity when we meet with them this week.

We’ve long called for a comprehensive investigation of the DDS corporate provider-based system, which costs the state $1.2 billion per year and involves the operation of more than 1,800 group homes.

While the IG’s Bureau of Program Integrity found in 2017 and 2018 that there were financial irregularities in the state’s much smaller network of some 200 state-operated group homes, the Bureau has so far not issued any similar reports on the privatized provider system. In fact, there has been no systematic investigation, as far as we know, of the provider system in Massachusetts since the 1990s.

In 1997, the Legislature’s House Post Audit and Oversight Committee found problems of abuse, neglect, and financial irregularities throughout the DDS system. The Post Audit report stated that DDS’s oversight of privatized care, in particular, raised “grave doubts about (DDS’s) commitment to basic health and safety issues and ensuring that community placements provide equal or better care for (DDS) clients.”

Some caveats on the DPPC data

Our analysis has involved taking the raw data in each file from the DPPC, sorting that data by provider, and counting the total number of complaints for each provider that appeared to have more than a minimal number of complaints. We also counted the number of complaints substantiated and referred for criminal investigation over the time period for each provider, and then calculated the percentages for each provider of total complaints substantiated and referred. The high numbers in each category are highlighted on the linked spreadsheet.

We would note that many abuse complaints are referred by the DPPC to district attorneys that are screened out for investigation by the DPPC itself because they don’t fall under the DPPC’s statutory jurisdiction. As a result, the number of referrals to the DA’s are often higher than the number of complaints substantiated by either the DPPC or DDS.

One other caveat about this data is that the DPPC has acknowledged to us that the numbers of complaints, substantiations, and referrals in its data refer to intake calls that the DPPC receives regarding abuse. There may be multiple intake calls for each actual occurrence of abuse. So the DPPC numbers may inflate the actual number of cases or occurrences of abuse that the agency investigates or refers for investigation. However, that potential inflation in the numbers shouldn’t affect the relative percentages regarding providers in the data.

DDS launches ‘licensing review’ following allegations of poor care in provider’s group homes

August 12, 2019 15 comments

The Department of Developmental Services is conducting a “special licensing and program integrity review” in response to allegations of poor care in group homes operated by a provider licensed by the Department.

In an August 8 statement provided to COFAR, DDS Commissioner Jane Ryder also said that DDS is investigating the allegations and is requiring the Springfield-based provider, the Center for Human Development (CHD), to implement a corrective action plan. The Department has also conducted unannounced visits to the residences, Ryder stated.

“DDS takes the health and safety of individuals it serves very seriously, and is conducting a thorough investigation into the allegations,” Ryder added.

Ryder’s statement was provided nearly a month after COFAR asked for comment from her regarding a series of allegations raised by Mary Phaneuf, the foster mother of Timothy Cheeks, a 41-year-old resident of a CHD group home in East Longmeadow.

Last year, Phaneuf began raising concerns with CHD and DDS about Tim’s care, including a lack of proper medical care for Tim and no documented visits to a primary care physician or dentist for seven years. Phaneuf also said there were no documented visits to a cardiologist for six years despite Tim’s having been born with a congenital heart defect.

Last week, CHD acknowledged the missed medical appointments for multiple clients, “failures to follow protocols,” and financial misappropriation in two residences. Those problems include an alleged failure to ensure that Tim was receiving Social Security benefits for at least two years, and the alleged diversion of food stamp benefits from Tim and at least one other client.

Despite the seriousness of those issues, an online June 2017 DDS licensure inspection report for CHD on the DDS website did not mention those or similar problems in CHD’s group homes. It was not clear whether the DDS special licensing and program integrity review is intended to examine whether the DDS licensure process fell short in the CHD case.

The 2017 DDS licensure report for CHD did not appear to note any serious issues with medical care in the CHD’s residential facilities except to state that medical plans for two residents “did not fully address all required elements.”  The report stated that “the vast majority of individuals in the survey sample were supported to receive timely annual physical and dental examinations, attend appointments with specialists, and receive preventive screenings as recommended by their physicians.”

In our July 9 email to Ryder, we asked “whether it is possible that the DDS licensure process is not sufficiently comprehensive or thorough to identify issues such as the ones cited (in the CHD case).”

COFAR also asked Ryder in that email whether DDS reviews abuse or other complaints or investigative reports as part of its provider licensure process. Ryder’s August 8 statement did not respond to either of those questions.

COFAR has called for a comprehensive investigation of the privatized DDS system, and has reached out the the Attorney General’s Office and to state policy makers and legislators for support for that. The Springfield Republican, which reported on Tim’s case last week, noted that Attorney General Maura Healey’s office recently met with COFAR, and quoted a spokesperson for Healey as saying they “are learning more about the issues they (COFAR) raised.”

The Republican  included a statement from James Goodwin, CHD president and CEO, apologizing for the issues raised by Phaneuf.

“The quality of our services — the care and support that CHD and Meadows Homes provide to our clients — is our most important value, and in these cases we have failed in not upholding that value,” Goodwin told the newspaper. “We apologize for these failures. We are committed to making the changes needed to regain the trust of our clients and families at Meadows Homes, and to continue to support their health and wellbeing.”

In a statement previously provided to COFAR, Goodwin listed a number of corrective actions that he said CHD has taken since January, including cataloging all medical visits in a database, tracking communication between guardians and caregivers, requiring more rigorous supervision of program leaders, and developing a system to automatically inform family members and guardians of medical appointments and their outcomes.

DDS group home provider acknowledges multiple clients missed dozens of medical appointments

August 6, 2019 17 comments

In the wake of a series of allegations identified by COFAR of poor care of a group home resident, the president and CEO of the nonprofit group home provider has acknowledged missed medical appointments for multiple clients, “failures to follow protocols,” and financial misappropriation in two residences.

The provider, the Center for Human Development (CHD), is funded by the state Department of Developmental Services (DDS). DDS relicensed CHD in 2017 after issuing a licensure report that did not appear to address those managerial problems.

In an August 1 statement provided to COFAR, James Goodwin, CHD’s CEO and president, said his organization has verified that eight clients in two of its group homes missed a total of 59 medical and dental appointments since 2015.

Goodwin said the missed appointments included primary care visits, specialty care visits, and eye and dental exams, and were “a result of failures to adhere to policies in two homes…”  He said it was “important to note that clients continued receiving prescription medications during this time, so many appointments were being kept.”

“We can’t comment on the specifics of an individual’s care,” Goodwin’s statement added. “We have identified instances of failures to follow protocols and isolated instances of inappropriate use of financial resources. All funds have been fully reimbursed. We acknowledge the need for improvement in oversight and strengthening of policies, and improvement in communications with family members and guardians, and we have taken substantial steps to make those improvements.”

Foster mother detailed a series of care problems

Goodwin’s statements were in response to a July 15 COFAR blog post, which detailed a series of problems with the care of Timothy Cheeks, a 41-year-old man with Down syndrome who lives in a group home managed by CHD in East Longmeadow.

Since late last year, Tim’s foster mother and guardian, Mary Phaneuf, has raised issues with CHD and DDS regarding Tim’s care at the residence including:

  • A lack of proper medical care for Tim, including no documented visits to a primary care physician or dentist for seven years;
  • No documented visits to a cardiologist for six years despite Tim’s having been born with a congenital heart defect;
  • A failure to treat Tim for two years for back pain and a degenerative back problem, and to fill a prescription for pain medication for him;
  • A failure to ensure that Tim was receiving Social Security benefits for at least two years;
  • The unexplained removal of Tim from his day program run by the Work Opportunity Center (WOC) in Agawam without informing Mary of that fact. (Phaneuf first discovered and raised this issue with CHD in 2017);
  • The diversion of food stamp benefits for Tim and at least one other resident of a CHD group home; and
  • Erroneous information listed in Tim’s 2018 Individual Support Plan (ISP), including an untrue statement that Tim had visited a primary care physician in September of that year. The doctor listed had apparently not seen Tim since 2011.

Despite the seriousness of those issues, an online June 2017 DDS licensure inspection report for CHD on the department’s website did not mention those or similar problems in the agency’s group homes.

Corrective policies cited

Goodwin said that immediately upon discovering the “failures in the program” in early January, CHD began making “extensive reviews of and changes to policies, increasing oversight and documentation of clients’ medical care and adding additional safeguards against individual failures to adhere to protocols.”

The medical needs of all clients in the program who were affected are now being met, Goodwin said. He maintained that the program failures “can be traced overwhelmingly to the actions of a single staff member.” While Goodwin did not identify that staff member, he was reportedly referring to a former manager of two of CHD’s group homes.

Goodwin also stated that there was “no indication that failures such as these took place at any other CHD programs besides the two Meadows Homes programs.”

Goodwin also said CHD has identified “one instance of impropriety with a food stamp benefit check in one of these programs.” He said all misappropriated funds were immediately reimbursed and that there was “no impact on program function or service.”

In addition, Goodwin said, CHD recently identified one instance of a total of $2,100 in “client money being accessed inappropriately and we have reimbursed the funds.”

A June 7 DDS complaint resolution letter cited two clients affected in two separate residences as a result of an alleged food stamp diversion. Mary Phaneuf also contends Tim is owed $2,400 in missed Supplemental Social Security Income (SSI) funds.

Goodwin’s statement added that “staffing changes and appropriate disciplinary action (have been taken) for personnel involved.” A CHD vice president later declined to say how many employees have been disciplined.

DDS commissioner has not commented on the matter

DDS Commissioner Jane Ryder has not responded to a July 9 email from COFAR asking for comment on the overall case or “whether it is possible that the DDS licensure process is not sufficiently comprehensive or thorough to identify issues such as the ones cited here.”

COFAR also asked Ryder in that email whether DDS reviews abuse or other complaints or investigative reports as part of its provider licensure process.

CHD CEO’s statement largely focused on missed medical appointments

Goodwin’s August 1 statement largely focused on the allegations of missed medical appointments. That, however, was only one of many concerns that Mary Phaneuf said she brought to the attention of the provider’s managerial staff late last year.

Phaneuf told COFAR that while CHD did begin in January to address the problem of missed appointments, the provider did not inform her of any plan it had to discover or address the underlying cause of the long-term neglect.

Phaneuf contended upper-level managers at CHD failed to keep their promise of routinely updating her on managerial changes or issues that directly affected Tim. That changed only after COFAR’s July 15 blog post was published, she said.

“Promises made by CHD and DDS to keep me informed of their progress to improve systems and further discoveries of other violations never happened. Until the blog, I had been ignored for months,” Phaneuf wrote in an email.

Goodwin’s statement to COFAR listed a number of “corrective actions” instituted by CHD “immediately…upon discovering the missed appointments,” including the following:

  • “Scheduling and fulfilling appointments to account for those that were missed and otherwise supporting the fulfillment of medical needs of all clients who missed appointments.”
  • “Extensive reviews of and changes to policies, increasing oversight and documentation of clients’ medical care, and adding additional safeguards against individual failures to adhere to protocols.”
  • A requirement that “all medical encounters … be catalogued in a database accessible to all members of the care team.” The database was implemented in March, Goodwin stated.
  • “Regular reviews of medical documentation by nursing staff and senior managers…”
  • Implementation of “compliance software to facilitate more effective oversight of medical appointments.”
  • “More rigorous supervision of on-site and program leaders is now mandated and checked for implementation.”
  • “Development (now underway) of a new protocol to support greater family and guardian engagement in medical decision making and medical care, and a system of automatic updating of family members and guardians on medical appointments and their outcomes.” The new protocol is scheduled to take effect on August 12, a CHD vice president stated.

It is certainly a positive development that CHD has responded to, and taken responsibility for, at least some of Phaneuf’s allegations about Tim’s care; and the corrective actions, if adhered to, should begin to address those problems.

To us, Goodwin’s statement falls short, however, in failing to address all of the allegations, and in largely placing the blame for the situation on a single staff member. When medical appointments are missed for multiple clients over a period of years, the problem points to failures in oversight at top levels of the organization.

In fact, it would have been better if Goodwin had personally accepted responsibility for the issues that Phaneuf raised, and made it clear that he intends to re-examine CHD’s entire managerial culture.

In our view, DDS Commissioner Ryder’s failure to respond publicly regarding this case is unacceptable. Unfortunately,  Ryder has established a disturbing pattern of circling the wagons and not publicly commenting when confronted with questions about her department’s responsibility for problems in the system.

We would also hope that Ryder and other top policy makers in the administration and the Legislature will begin to acknowledge that the problems in this case are not unique. Systematic shortcomings in the care of persons with developmental disabilities in Massachusetts are ongoing and are being made worse by the expanding privatization of services.

A comprehensive investigation of the DDS system is needed, and we would love to see the governor, attorney general, DDS, and key state legislators support that idea.