New data provide more evidence that the DPPC should do all abuse investigations

January 15, 2019 1 comment

New data provided by the Massachusetts Disabled Persons Protection Commission (DPPC) and the Department of Developmental Services (DDS) raise further questions about the ability of DDS, in particular, to adequately investigate cases of abuse and neglect within its system.

As such, we think the data provide yet a further reason to place all investigative resources and functions within one independent agency — the DPPC.

The latest data, received under Public Records Law requests to both agencies, show that not only does the DPPC have fewer abuse investigators than does DDS, but the DPPC investigators themselves appear to have lower caseloads than do their counterparts at DDS.

Yet, the DPPC is the state’s sole independent agency charged with investigating abuse and neglect of disabled adults. As we have reported, the DPPC is so poorly funded that it has to refer most of the complaints it receives to DDS and other service-providing agencies to investigate.

The caseload data comes on top of previous data we received showing that the DPPC investigators tend to find that a higher percentage of abuse allegations have merit than do their counterparts at DDS. Given the DDS caseloads are higher than the DPPC’s, it appears possible that DDS investigators aren’t able to do investigations as thoroughly DPPC investigators.

The latest data obtained from DDS and the DPPC also show that the number of substantiations of abuse allegations in general has been dropping in investigations done, particularly by DDS.

DDS’s main function is to manage and oversee care to the intellectually and developmentally disabled through a network of both state-operated and corporate provider-operated group homes and other facilities. Because of that, DDS appears to face a conflict of interest in investigating allegations of abuse and neglect in its own system.

Higher DDS caseloads

The chart we created below shows the consistently higher average caseloads that DDS investigators have had compared with the DPPC’s investigators, although the DPPC’s caseloads have been rising in recent years.

Between Fiscal 2010 and 2018, DDS’s yearly caseload has averaged 51.9 abuse investigations per investigator, while the DPPC’s average caseload has been 27.9.  (DDS has employed an average of 31.4 abuse investigators each year while the DPPC has employed an average of 4.6 investigators each year in that time frame.)

chart on dppc and dds investigation caseloads fy10-18

Source: DPPC and DDS data

Based on the DPPC’s data, our second chart below depicts the dropping abuse substantiation rate each year for both the DPPC and DDS.

chart on total dppc and dds abuse substantiation rate fy 04-18

According to the data, the annual percentage of abuse allegations that have been substantiated by DDS and the DPPC dropped from a high of 28% in Fiscal 2006 to about 13% in Fiscal 2018. The conclusion we draw from this particular data is that funding to both agencies for investigations has been increasingly inadequate.

The DPPC’s higher abuse substantiation rate since Fiscal 2012

The data going back to Fiscal 2004 show that the DPPC began consistently substantiating a higher percentage of abuse allegations than DDS starting in Fiscal 2012. There were three years between Fiscal 2004 and 2011 in which DDS substantiated a higher percentage of allegations than did the DPPC.

There don’t seem to be clear reasons for either the relatively higher abuse substantiation rate by the DPPC or the dropping substantiation rate by DDS, in particular, although, as noted, one reason might be DDS’s relatively high caseloads.

The DPPC’s policy to reserve more serious cases for itself

It’s possible that the DPPC has had a higher abuse substantiation rate because the agency has tended to reserve what might be considered the most serious abuse cases to itself, and that those more serious cases would be more likely to be substantiated than would the less serious cases assigned to DDS.

At first glance, a policy document we received from the DPPC on assigning cases would seem to support that theory.  The policy lists a number of instances in which the DPPC assigns more serious cases to itself provided that it has the resources to do so.

But the DPPC policy is dated 1998. There doesn’t seem to be a clear pattern of abuse substantiations from either the DPPC or DDS that lines up with the policy or its revisions in 2013 and 2016.

DDS says DPPC substantiation data misleading

In a response earlier this month to our questions, DDS maintained that the data we used from the DPPC doesn’t reflect the true abuse substantiation rates for DDS.

The DDS response included a lengthy explanation for why this is so, but the gist of the explanation seems to be that the DPPC data doesn’t account for all of the cases that DDS investigates, and that the DPPC counts the cases differently than DDS. We don’t think, however, that any such differences would affect the overall results of our analysis because we used the DPPC’s substantiation-rate data for both the DPPC and DDS, and we are assuming that the DPPC has been consistent in how it accounts for the cases investigated by both agencies.

The DDS’s conflict of interest

As we’ve stated, the data point toward the logic of having all abuse investigations done by one independent agency. The current system under which abuse investigations are done by separate agencies makes no sense, and leads at the very least to the perception that the investigations done by DDS are not thorough and cannot be relied upon.

As we reported in our January 2004 issue of The COFAR Voice, the DPPC itself issued a position statement at that time charging that DDS (then the Department of Mental Retardation) and other state agencies were “vulnerable to pressures that could compromise the integrity of their investigative findings (in abuse cases).”

Filing legislation to place in investigative resources solely within the DPPC

We will share our findings regarding the DPPC and DDS investigation data with the Legislature’s Children, Families, and Persons with Disabilities Committee. We hope these findings will concern them as much as they concern us.

We are also seeking to file legislation in the current legislative session to place all resources for abuse and neglect investigations within the DPPC, and to place all DDS provider licensure and monitoring resources within an independent state Office of Quality Assurance.

The Children and Families Committee initiated a review of the DDS system in January of 2018 and called in the DDS commissioner and DPPC executive director on two occasions last year to testify about abuse and neglect in the DDS system. Both officials insisted the system is functioning smoothly and offered no suggestions for changing it.

The families in our organization know that the system isn’t fine and it isn’t running smoothly.  The Children and Families Committee, however, has not allowed those family members and guardians to testify publicly about their experience with the system.

We hope things finally begin to change in the new legislative session, which just started this month, and that the Legislature will begin to take concrete steps to protect the developmentally disabled in this state from abuse and neglect.

A clear starting point would be to give the DPPC, the state’s independent abuse investigation agency for the disabled, the necessary tools and authority to do the job.

Advertisements

Illinois transparency laws could be a model for programs providing care to disabled in Massachusetts

January 2, 2019 5 comments

When it comes to the public’s right to know, Massachusetts state government has not been in the forefront in recent years, and issues concerning the developmentally disabled appear to be no exception.

Not only are investigative reports on abuse and neglect of the developmentally disabled largely kept secret in this state, but those reports are primarily done by the same agency that provides and manages services for the disabled. In those situations, there appears to be little incentive to let the public in on what the investigations have revealed.

As the new two-year legislative session begins in Massachusetts, COFAR will push for legislation that would make information about the care in the Department of Developmental Services system more available to the public. One place to start appears to be the adoption of online information about performance of DDS provider agencies and abuse and neglect in that system.

Such information, which exists in Illinois, could help families and guardians in making the difficult decision on placement of their loved ones in DDS-funded facilities.

Illinois abuse data on providers could be a model for Massachusetts

Illinois has both a human services “provider scorecard,” which offers comparative information about group home provider performance, and an online database that allows comparisons of numbers of abuse allegations and abuse substantiations among individual providers in the state. One caveat about Illinois is that these information sources appear to be extremely difficult to locate on that state’s Department of Human Services website.

The Illinois database appears to be a response to a series of articles in 2016 by The Chicago Tribune, which had described a system of privatized group homes in that state in which “caregivers often failed to provide basic care while regulators cloaked harm and death with secrecy and silence.”  The relative lack of coverage of these issues by mainstream media outlets in Massachusetts, and the relative lack of interest as well in the Legislature, may explain why few if any of these sources of online information are available in this state.

The DDS in Massachusetts does provide online provider licensure reports. But these reports on individual providers tend to contain vague and generic findings and recommendations that make comparisons among providers difficult. The licensure reports, which are also difficult to find on the DDS website, don’t reveal or discuss findings of abuse or neglect within the residential or day program facilities.

At least some of that comparative information that is missing in Massachusetts can be found on the Illinois Human Services Department website.

Provider Scorecard

Among the comparative online information available about the Illinois human services system are licensure scores for providers in the state known as BALC scores. As the website notes, the BALC scores are divided into several categories:

A (BALC) score of 100% indicates the provider is in full or acceptable compliance;

93-99% is considered an acceptable standing;

80-92% results in a written “Notice of Violations” and requires an acceptable plan of corrections;

70-79% indicates the agency is minimally compliant and will be on probation for up to 90 days; and

69% and below results in the disallowance of new admissions.

While the DDS licensure system in Massachusetts provides ratings for providers on dozens of individual measures, the ratings are difficult to understand, and there is no way for the public to compare providers on overall performance as there is on the Illinois provider scorecard site.

Also potentially important on the Illinois provider scorecard are comparative ratings of the average health risk and average maladaptive behavior of the residents of provider residences. No such information is available in Massachusetts.

The Chicago Tribune stated that the Illinois provider scorecard includes group home inspection results and links to online copies of investigative findings involving abuse, neglect or financial exploitation. We were not able, however, to locate those links.

Disclosure of data would supplement an abuse registry

The types of online information available or reportedly available in Illinois would be something that would potentially supplement a proposed registry in Massachusetts of caregivers who have had abuse charges substantiated against them.

The proposed registry in Massachusetts came close to enactment last year, but ultimately was not approved. Even that registry, however, would itself not be transparent in that the names of the persons listed in it would not be made public under the legislation that was under consideration in the just-concluded 2017-2018 legislative session. So it is important that there be information about DDS-funded programs that individuals, families, and guardians can consult to judge the performance of providers for themselves.

The Illinois abuse data list needs to be viewed cautiously, but we think most people looking for residential placements would do that.

For instance, in the Illinois substantiated abuse database, the most important column in the data appears to be the number of substantiated abuse allegations per 100 people served for each provider.

That data can vary widely from year to year, even for the same provider. As the charts we developed from the data for two of the providers show, the Village Inn Cobden had a higher rate of substantiated abuse than the Royal Living Center in Fiscal 2017, but the Village Inn had zero substantiated abuse allegations in Fiscal 2015 and 2016. In both cases, the number of allegations of abuse rose substantially over the three-year period.

 

Illinois abuse allegations charts Royal and Village

Public disclosure needed of abuse investigation reports

According to the Chicago Tribune, Illinois Human Services Secretary James Dimas told Senate and House lawmakers that his department had launched reform measures to heighten enforcement of group homes statewide and increase public transparency of the system.

The Tribune stated that:

…one of the most sweeping reforms outlined by Dimas would provide limited public access to previously sealed investigative files. The department is working with the Illinois attorney general’s office to provide group home addresses and full enforcement histories to families and guardians.

“I’m committed to transparency,” said Dimas, who was appointed in May 2015 by Illinois Gov. Bruce Rauner.

We think similar transparency is needed for investigative reports done by the Massachusetts Disabled Persons Protection Commission (DPPC). As we have reported, the DPPC’s regulations seem to go well beyond the agency’s enabling statute in stating that “the records of the Commission shall not be considered ‘public records’…” (my emphasis).

The DPPC regulations exempt from disclosure all “investigative materials” compiled by the agency. And the regulations state that the DPPC can determine that “the mere removal of identifying personal data would be insufficient to protect existing privacy interests, or that disclosure would not be in the public interest…”

We maintain that the DPPC’s enabling statute does not state that DPPC records are not public or that all investigative materials are exempt. Additional legislation may be needed clarifying this.

Finally, we would argue that DDS itself should not be involved either in investigating abuse or neglect within its own system, or even in licensing provider-run facilities. Both of those ongoing practices lead to conflicts of interest for DDS and to reduced transparency.

That’s why we will support legislation in the new session along the lines of a bill proposed by Representative Angelo Scaccia,which would take the group home licensing function out of DDS and make it an independent function. That legislation could be combined or paired with legislation to take abuse and neglect investigative functions away from DDS and put them into the DPPC.

Ultimately, we want to see a system of care for persons with developmental disabilities in Massachusetts that is both transparent and free of serious conflicts of interest. We hope the media and the Legislature are truly interested in those goals as well.

DDS lags independent DPPC in abuse substantiations

December 18, 2018 1 comment

Although the state Department of Developmental Services investigates far more abuse allegations of the developmentally disabled in Massachusetts than does the independent Disabled Persons Protection Commission (DPPC), DDS found a lower percentage of the allegations to have merit than did the DPPC between Fiscal Year 2015 and the present, data provided by the DPPC show.

While the DPPC is technically the lead state agency in investigating complaints of abuse and neglect of the disabled in the state, the agency is so poorly funded that it is forced to refer most of the complaints it receives to DDS and other agencies to investigate.

As the chart below shows, the DPPC “substantiated” an average of 22.7% of the abuse allegations that the agency itself investigated from Fiscal Year 2015 through 2019. During that same time period, DDS substantiated an average of only 13.6% of the allegations that the Department itself investigated.

The chart is based on the DPPC data, provided to COFAR under a Public Records Law request.

Chart on DPPC and DDS substantiated abuse cases

When allegations of abuse are substantiated, DDS and its corporate providers of care are usually required to take corrective measures, which can include providing training, changing procedures, and barring alleged abusers from further employment in the system. The DPPC has a separate State Police Detective Unit that refers some of the allegations to local district attorneys offices for separate criminal investigation and prosecution.

The DPPC, which was established in 1987 as an independent agency to investigate allegations of abuse and neglect of adults with intellectual and other disabilities, had only four investigators on its staff (not counting the State Police Unit) as of Fiscal Year 2017, according to its latest online annual report. Despite that, the agency received more than 11,000 reports of abuse of the disabled that year, according to the annual report.

According to the DPPC data, the agency itself investigated an average of only 144 abuse complaints per year between Fiscal Years 2015 and 2018, the last year for which complete data were provided. During that same period, the DPPC referred an average of 1,743 complaints per year to DDS to investigate.

But while DDS does have more investigative resources than the DPPC, DDS’s main function is to manage and oversee care to the intellectually and developmentally disabled through a network of both state-operated and corporate provider-operated group homes and other facilities. As such, DDS appears to face a conflict of interest in investigating allegations of abuse and neglect in its own system.

The DPPC data for Fiscal 2019 are only partial so the percentage of substantiated cases between the DPPC and DDS may not vary as widely as of the end of the year as they appear to do now. But there seems to be a pattern going back to Fiscal 2015 that verifies concerns we’ve raised that DDS has an incentive to downplay complaints of abuse and neglect in its own facilities, whether they are state or provider-operated.

The DPPC doesn’t appear to want to talk with us. Neither Nancy Alterio, the executive director of the agency, or anyone else there has agreed to several requests for an interview.

Apparently, very little has changed since 2004 in the relationship between the DPPC and DDS except that prior to at least that year, DPPC officials were willing to state publicly that DDS was compromised in investigating abuse within its own system.

The January 2004 issue of The COFAR Voice noted that the DPPC had issued a position statement charging that DDS (then the Department of Mental Retardation), the Department of Mental Health, and other state agencies were “vulnerable to pressures that could compromise the integrity of their investigative findings (in abuse cases).”

There have been instances, the DPPC statement noted, in which information contained in investigative reports had been altered “to absolve the service-providing agency from liability.”

The DPPC statement added that among the reasons that the DPPC should conduct abuse investigations internally were that it would lend integrity to the investigation process and would provide a “political safety valve” to other agencies, whose own investigations might otherwise be branded as “whitewashes.”

The DPPC statement even compared the investigations of abuse by service-providing agencies to the recent sex abuse scandal within the Catholic Church in which the system had “closed its eyes to its failings and attempted to protect itself by protecting the wrongdoers within it.”

Thomas J. Frain, COFAR’s president, is also quoted in the 2004 article, as saying, “DMR is dependent on these providers for services and is going to be very reluctant to sanction them for either poor service or abuse. We need an independent organization like the DPPC to do this.”

Seeking additional information

Last week, we asked the DPPC for additional data, including:

  1. The number of investigators employed by DDS and the DPPC to investigate complaints of abuse  from Fiscal Year 2004 to the present.
  1. Any written agreements between the DPPC or DDS or written policies or guidelines that concern the process of determining which abuse complaints are assigned for investigation by the DPPC and which complaints are assigned for investigation by DDS.

We have also asked both the DPPC and DDS for comment on the data showing a higher percentage of substantiation of abuse complaints by the DPPC. So far, we have not heard back from either agency on that question.

And we’ve asked the DPPC whether they stand by the agency’s statement prior to 2004 that the agency should have the resources to conduct all abuse investigations internally. We’ve asked DDS as well whether they agree that the DPPC should conduct all abuse investigations.

We’ll be back here to report on the answers we get from each agency. It’s certainly possible that the DPPC and DDS will provide a reason we haven’t thought of as to why the abuse substantiation rates differ between each agency. (We would note that the overall percentage difference between 2015 and the present appears to be large enough that it is likely not due to chance alone.)

Whatever that reason given, if a reason is given, for the difference in the substantiation percentages might be, we’ll report it. But the perception of a conflict of interest remains in having the DDS investigate its own system. Thirty-one years after the creation of the DPPC, that needs to be changed.

 

Judge Joseph L. Tauro, a giant in the treatment of the developmentally disabled, dies at 87

December 3, 2018 Leave a comment

Retired U.S. District Court Judge Joseph L. Tauro, who oversaw the upgrade of the institutional system of care for the intellectually and developmentally disabled in Massachusetts for decades starting in the 1970s, died on November 30 at the age of 87.

Tauro changed the course of history for persons with developmental disabilities in Massachusetts. His many rulings in the landmark Ricci v. Okin class action litigation over conditions in the institutional system in the 1970s and 1980s improved the lives of thousands.

Judge Tauro

The Honorable Joseph L. Tauro

“Judge Joseph L. Tauro treated developmentally disabled individuals and their families with dignity and compassion, and he listened when no one else would,” said Colleen Lutkevich, COFAR executive director. “In 1972 and for the next twenty years, he took a disgraceful system of care where people were warehoused in overcrowded facilities with minimal services, and he used the power of his office and the law to bully and cajole the state and federal government into doing the right thing.”

Tauro ruled in the case of Ricci v. Okin, a combined class-action lawsuit first brought by activist Ben Ricci over the conditions at the Belchertown State School.  Those conditions were chronicled in Ricci’s book, Crimes Against Humanity, and later in books such as You’ll Like it Here, a 2016 account  by Ed Orzechowski of the life of Donald Vitkus, a survivor of the former Belchertown State School.

In 1972, separate lawsuits were initially filed on behalf of the residents of five state schools: Fernald, Dever, Monson, Wrentham, and Belchertown. The lawsuits charged that the facilities were understaffed and that conditions in them were inhumane.

Tauro, who visited the facilities to observe the conditions first hand, noted two decades later in his 1993 disengagement order from the case that the legal process had resulted in major capital and staffing improvements to the facilities and a program of community placements. Together, those improvements and placements had “taken people with mental retardation from the snake pit, human warehouse environment of two decades ago, to the point where Massachusetts now has a system of care and habilitation that is probably second to none anywhere in the world.”

“Services in the facilities were turned around through increased funding and staffing,  and the community system of the Department of Developmental Services was also built, allowing appropriately placed residents to find new homes and jobs in cities and towns all across Massachusetts,” Lutkevich said.  “For those who remained in the facilities, their days also became meaningful, with clinical services, and therapeutic, recreational and work opportunities never before thought possible.”

Involvement in the effort in the 2000s to keep Fernald open

Despite his official disengagement from the Ricci case, Tauro’s involvement in the case did not end after 1993. Eleven years after his disengagement order, he went on to play a dramatic role in an effort by the original plaintiffs in the case to keep the then Fernald Developmental Center open in the face of attempts by the then Romney and later Patrick administrations to close it along with other remaining developmental centers in Massachusetts.

Ultimately, Tauro’s 2007 ruling in the case that the Fernald Center should remain as a residential option to its residents was overturned by the First Circuit U.S. Court of Appeals.

The Appeals Court ruling dealt an enormous blow to the decades of work that Tauro had done in the Ricci case, in part, because the appeals court’s decision included no deference to Tauro’s rulings and expertise. Nevertheless, Tauro’s re-involvement in the case after 2004 demonstrated his caring and humanity as clearly as his earlier involvement had in the 1970s and 1980s.

Speaking about the residents of the Fernald Center during a November 2004 hearing in his courtroom on the potential reopening of the case, Tauro noted that many of those residents were elderly. “In the remaining moments of their lives,” he said, “they ought to be treated with great dignity.”  His remark drew strong applause from the close to 200 observers in the courtroom, many of whom were family members of the residents.

Successive administrations undercut Tauro’s rulings in the Ricci case

Efforts to chip away at Tauro’s legacy in the Ricci case began in the early 1990s under then Governor William Weld, who moved to close nine state-run human services facilities in Massachusetts, including three developmental centers serving the developmentally disabled.

Then in 2003,  then Governor Mitt Romney announced plans to close at least four of the six remaining state-run developmental centers. All of those facilities had undergone upgrades in care and conditions as a result of Tauro’s involvement in the Ricci litigation. Hundreds of millions of dollars had been spent on the upgrades.

Starting with Fernald, those remaining facilities slated for closure included the Glavin, Monson, and Tampleton centers.

Plaintiffs charge that Tauro’s disengagement order had been violated

In 2004, Beryl Cohn, an attorney for the original Ricci plaintiffs, charged that the Romney administration was trying to close Fernald in violation of Tauro’s 1993 disengagement order.  Cohen cited the administration’s planned closure of Fernald in conjunction with
“unprecedented” personnel reductions and budget cuts in the then Department of Mental Retardation system.

According to the plaintiffs, some 30 years after the Ricci class action lawsuit had been filed, the Romney administration had allowed a recurrence of some of the same conditions at certain of the state facilities that had sparked the original case, including insufficient staffing, lack of equipment, delayed maintenance,  infestation of vermin, and other problems.

Tauro’s disengagement order had also required that before anyone could be transferred out of a state-run facility, care in the new location must be certified as equal or better.

In July 2004, the then Fernald League and other plaintiffs filed a motion in U.S. District Court to seek Tauro’s renewed involvement in the Ricci case.

During a contentious hearing in his courtroom in November of 2004,  Tauro appeared to accept the argument that a rush to close Fernald and the other facilities without adequate plans for the welfare of their current residents could violate his disengagement order. He also noted that many communities had not accepted group homes for the developmentally disabled, and that it could be difficult to find placements for Fernald residents.

“What’s the advantage in hurrying to speed up the closing (of Fernald) if it’s going to speed up litigation that’s going to last for five years?” Tauro said in pointed remarks to counsel for the Department of Mental Retardation and DMR Commissioner Gerald Morrissey, who was in attendance. “I don’t know if I’ll accept this case. If I do, I’ll come up with a solution…Let’s get it done right so everyone applauds it.”

Tauro forbids discussions of transfers from Fernald 

In January 2005, Tauro stated that he was prepared to step back into the case if Cohen were to demonstrate that care and services to transferred individuals were being cut. He ordered DMR officials to provide Cohen with Individual Support Plans (ISPs) for all Fernald residents, including those who had been transferred elsewhere.

Over the next six months, Tauro continued to hold hearings. In June of that year, he warned the administration not even to discuss transferring residents out of Fernald with families unless the ISPs stated the moves were appropriate. “If there is no ISP in place, then
there will be no discussions on transfers (out of Fernald),” Tauro said, as DMR Commissioner Gerald Morrissey and his legal staff sat before him in the courtroom. “If that’s not going to happen, then we are going to have a little trouble.”

Tauro appoints U.S. attorney as court monitor in Fernald closure 

In February 2006, Tauro appointed then U.S. Attorney Michael Sullivan as Court Monitor in the case and asked Sullivan to review the transfers by DMR of 49 residents from Fernald since 2003.  Pending the completion of Sullivan’s review, Tauro ordered a halt to all further transfers from Fernald to other locations.

In March 2007, in a stunning blow to the Fernald closure advocates, Sullivan recommended to the newly installed Patrick administration that Fernald remain open.

In making the recommendation that Fernald remain open, Sullivan maintained in his report to Tauro that while the level of care there might be able to be duplicated elsewhere, the loss of familiar surroundings and people “could have devastating effects [on the residents] that unravel years of positive, non­abusive behavior.” Nevertheless, Sullivan concluded that the state had followed the letter of Tauro’s 1993 disengagement order in that administration officials had technically certified that persons transferred from Fernald would receive equal or better care.

Sullivan also told Tauro that he found two areas of “significant concerns” in community-­based care. One involved the delivery of medical services in the community, and the second involved the potentially higher risk of abuse and neglect in community­-based residences than in the facilities and other state-­operated residences.

Final ruling that Fernald must be offered as a residential option

Despite Sullivan’s recommendation, the Patrick administration did not back away from the Romney administration’s position on the developmental centers, and continued to press ahead to close Fernald.

That led to Tauro’s final ruling in August 2007 that Fernald residents and their families and guardians must be offered the option of remaining at Fernald. The ruling was seen by the administration as preventing the closure of Fernald, and the administration appealed the ruling to the First Circuit U.S. Court of Appeals.

Tauro’s final ruling is overturned

Without considering the merits of Tauro’s reasoning in his 2007 ruling, the three-judge federal appeals court panel ruled in October 2008 that Tauro never had jurisdiction to reopen the Ricci case. As such, the appeals court allowed the Patrick administration to proceed with Fernald’s closure. That closure, however, was not completed for another six years as more than a dozen families and guardians of the remaining residents exercised their right to administrative appeals of the transfers of the residents.

Tauro seals the records

After the First Circuit Court of Appeals overturned his 2007 ruling that Fernald remain as a residential option, Tauro closed the Ricci case and sealed the documents. Among those documents was a report that Sullivan had provided to Tauro on what appeared to be the involuntary removal from Fernald of Anna Tross,  a 91-year-old resident of the facility.

According to testimony at a March 2008 hearing held by Tauro into the circumstances surrounding Tross’s removal from Fernald, Tross had told several people that she didn’t want to leave Fernald.

Appeal to U.S. Supreme Court to restore Tauro’s Fernald order fails

In February 2009, the Fernald plaintiffs, represented by Hofstra University law professor Leon Friedman, filed a petition for Certiorari with the Supreme Court, seeking to restore Judge Tauro’s 2007 order keeping Fernald open as a residential option.

The petition also sought to resolve the issue of whether Appeals Courts should give deference to district court decisions in consent-decree cases.  In this instance, the First Circuit Court acknowledged that it had not given any deference to Judge Tauro, despite his 35 years of expertise in overseeing the Ricci case.

The Supreme Court declined without comment to issue a Writ of Certiorari to consider the Fernald plaintiffs’ appeal.

Created national models

The Boston Globe noted that in his 41 years on the bench, Tauro “crafted decisions that created national models not only for the care of the developmentally disabled, but also for the rights of the mentally ill to refuse unnecessary medication and avoid solitary confinement except in emergency situations.”

“Whatever powers the Constitution has granted our government, involuntary mind control is not one of them, absent extraordinary circumstance,’’ Tauro wrote in a decision in the 1970s that established what are known as “Rogers Orders,” protecting the rights of the mentally ill.

“Judge Tauro was a fearless judge and a moral humanitarian who made the ‘impossible’ possible,” Lutkevich said. “He nearly single-handedly changed the lives of thousands of individuals with intellectual disabilities and their families.  COFAR families are forever grateful to him.  May he rest in peace.”

Father and sister will finally be allowed contact with disabled woman as 3-year DDS family-separation order is eased

November 13, 2018 3 comments

After three years, a state employed guardian is at least partially lifting a ban on family contact with a developmentally disabled woman, and is allowing the woman’s father and sister to visit her.

In a November 6 email to Ashley Barr, the disabled woman’s sister, Dorothy Wallace stated that she was granting permission to Ashley and to David Barr, the woman’s father, to visit the 30-year-old woman for the first time since November 2015. The woman has been diagnosed with an intellectual disability and mental illness.

Wallace has never clearly explained the reason for her family separation policy, which has nevertheless been upheld by the Department of Developmental Services. DDS pays Wallace to serve as a guardian to the woman and to other departmental clients.

Chelsea, David, and Ashley Barr

David and Ashley Barr. They have been prohibited, for unclear reasons, from contact with their developmentally disabled family member for the past three years.

In her email, Wallace wrote that she would now allow visits because the woman’s mother, Nancy Barr, has 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.

Nancy Barr pled guilty on November 6 to sexual assault charges and was sentenced to two years in prison. Leone pled guilty to similar charges in May and is serving a three to five-year prison term. The sentencing of both Leone and Nancy Barr had repeatedly been delayed during the past year.

During the period of the assaults, the woman had been under the care of her mother and had been living in her mother’s home. David Barr said that Nancy has also been diagnosed with mental illness.

Neither David nor Ashley, nor any other members of the family were involved in the abuse of the disabled woman or were ever charged in the case.

Yet, for the past three years, Wallace prohibited all members of the family other than an aunt from having any contact with the woman, and had not even informed the family as to where she has been living. We are withholding the woman’s name because she was a victim of sexual assault.

Ashley, whose first visit with her sister following the lifting of the ban was today at a DDS area office, said her sister appeared alert and happy to see her and her father. Regular weekend visits will be scheduled for the foreseeable future at a group residence in Haverhill in which her sister is now living.

Ashley also said she intends to apply in court to become her sister’s guardian and that David is supporting her in that.

Ashley told COFAR that in the months prior to the November 2015 ban on visitation, her sister appeared drugged when they were allowed to visit her, and, in one instance, did not appear to have been bathed.

COFAR has repeatedly asked Wallace and DDS for an explanation for the family contact ban specifically on David and Ashley. In an email to both Wallace and DDS Commissioner Jane Ryder on November 9, I also asked what the sentencing of Nancy Bar, in particular, had to do with the family separation policy.

David and Ashley had been among the most involved family members in the woman’s life and care, and have led the family’s effort to resume contact with the woman. To date, neither Wallace nor Ryder have responded to our queries about the case.

In her November 6 email, Wallace implied that she is stepping down as the woman’s guardian, stating that, “With the completion of the sentencing (of Nancy Barr), I have fulfilled my obligation to (the disabled woman) and as promised to Ashley and Mr. Barr they can now coordinate visits with (the woman).”

We have never seen another case in which such a complete and lengthy prohibition on contact was imposed on family members who were not charged or, as far as we know, accused of any serious misconduct with regard to a disabled individual. As we’ve said before, we think this ban has been enforced in violation of DDS regulations, which state that people in the Department’s care have the right …“to be visited and to visit others under circumstances that are conducive to friendships and relationships…”

We think there is a fairly universal consensus that family separation in social services should be imposed only as a last resort, and then should be used sparingly and for as short a time as possible. If family separation is imposed, authorities should be transparent about it and communicate as much information as possible to those family members affected. In our view, none of those criteria were met in this case.

During the past three years, different reasons have been given to the Barr family for the separation policy:

  • In an August 2015 hearing in probate court, Wallace testified, according to the hearing transcript, that she was imposing restrictions on contact between the woman and her father and sister because David and Ashley became overly emotional when they had been allowed to visit her.
  • Wallace contended that those visits, which took place in hospital settings after the arrests of John Leone and Nancy Barr on the assault charges, caused the woman to exhibit psychotic symptoms afterwards.
  • Last February, Ashley was told by DDS General Counsel Marianne Meacham that there was concern on someone’s part that a visit from David and Ashley would somehow make the woman “lose focus” in preparing to testify in the trial of Leone and Nancy Barr. Meacham told Ashley that visits would be permitted once the trial, which was originally scheduled to be held in April, was over.
  •  Despite Attorney Meacham’s contention that the ban on family contact was related to the then ongoing criminal case, a spokesperson for the D.A.’s office told COFAR in February that the D.A. was not responsible for the ban, and that it had been ordered by Wallace.
  • And despite the assurances given to Ashley, visits with her sister were not scheduled even after Leone pled guilty to sexual assault last May. David and Ashley were now told they would not be allowed any contact with the woman until Nancy Barr was sentenced in the case. That sentencing occurred only last week.

DDS officials appeared to be biased against the family

As COFAR reported, Wallace and other DDS officials made a number of statements about Ashley and David during the August 2015 probate court hearing that appeared to indicate a bias against them.

Many of the statements appeared to be hearsay or to lack  foundation, including Wallace’s statement that hospital clinicians told her the woman exhibited psychotic symptoms after visits from David and Ashley. At the time of her testimony, Wallace had been appointed as the woman’s temporary guardian.

The court hearing concerned a request by David and Ashley that they resume regular contact with the woman and that David be appointed as her permanent guardian. The judge, however, ruled instead in favor of the appointment of Wallace, the candidate recommended by DDS, as the woman’s permanent guardian. David Barr had tried without success to gain guardianship of the woman after his divorce from Nancy Barr in 2003.

Despite the judge’s ruling in 2015, the court does not appear ever to have issued an order banning any members of the family from having contact with the woman.

Ashley acknowledged she and her father did become emotional during visits with her sister prior to the complete visitation ban in November 2015 because she appeared upset at being kept isolated from them and often appeared to be over-medicated.

“For several visits we did cry in front of (her sister), I mean how could we not?” Ashley said in an interview in 2016. “She was alone, scared, by herself, and just went through a horrific thing for about two years. So yes, my father and I did cry, and I was an emotional mess for a very long time.  Watching my sister all drugged up, she could barely talk, and given the state she was in, it was very hard to keep it in. I walked out of the room most of the time so my sister wouldn’t see me.”

In one of the last instances in which they were allowed to visit the woman, Ashley said it appeared she had not been bathed.  Ashley said she personally gave her a shower at the hospital. Her hair was so dirty and matted, Ashley said, that she had to use an entire bottle of shampoo and conditioner to untangle it.

Little information and little help from legislators

After the woman told a family friend about the alleged abuse in 2014, the friend reported the matter to police, and the woman was immediately removed from her mother’s care. She was apparently placed in a shared living arrangement, but that location was not disclosed at the time to any other members of the family.

In the months that followed, the family was only sporadically informed about their family member’s whereabouts.  Ashley and her father said that virtually no information was provided to them for the first month after her removal. They were then allowed to visit her only a handful of times, either at a DDS area office or in Massachusetts hospitals to which she was admitted, reportedly after psychotic episodes.

David and Ashley said they tried for months after the ban on further contact was imposed to get answers from DDS and from Wallace, and got little or no response from them. They also contacted their local legislators and got little help, and even went to the media, but were unable to get any news outlets to report their story.

Ashley said the ban on contact was so complete that when she found out in May 2016 that she was pregnant, Wallace denied her request that her sister be allowed to come to the baby shower. She said Wallace also told her that her sister would not be informed that she was pregnant.

One aunt allowed visits, another blocked

For unknown reasons, the only family member who has been allowed to visit the woman has been a maternal aunt who apparently agreed not to reveal the woman’s location to Ashley or David. The aunt told COFAR, however, that she thought David and Ashley should be allowed to visit the woman.

In the meantime, another aunt of the woman’s as well as a family friend were blocked from visiting her.

In an interview with COFAR in August of this year, Susan Zeytoonian, a paternal aunt of Ashley’s, said she had accompanied Ashley to visit the woman shortly before Wallace banned all family contact. Zeytoonian said that prior to the removal of the woman from her mother’s care, the woman had frequently spent time at her house.

According to Zeytoonian, the woman was happy to see them during their 2015 visit and “came runnng down the hall.” She said she had not seen her niece since that visit.

The family friend who initially reported the alleged sexual abuse of the woman to police had initially been allowed to visit her. However, the friend told COFAR that when she tried to visit the woman at Tewksbury State Hospital in April 2016 on her 28th birthday, she was told that she was no longer there.

The friend said she was also told by a staff member at the hospital that she too had been placed on a no-visitor list.  She said she was not given a reason for that prohibition.

Disability Law Center tried to find a solution in the case

In early 2017,the Boston-based Disability Law Center temporarily intervened in the case to ask a state-appointed attorney who is representing the woman, to support family visits if the woman wished that. However, that effort was not successful.

The attorney, Melissa Coury Cote, told COFAR in March 2017 that she would not support court permission for visits to the woman by David or Ashley Barr, despite the DLC’s request. Cote provided no reason for opposing family visits other than to say that the woman had not specifically asked her to allow visits from her father and sister.

However, Ashley Barr said at the time that her sister had recently called her father on two occasions and said she missed her family and wanted to see them. The calls were apparently unauthorized. Ashley said she and her father didn’t know whose phone the woman used to contact them.

While we are glad that a step toward reuniting the family has finally been taken by Wallace and DDS, we remained concerned that the Department and its professional guardians do not appear to operate in accordance with the Department’s own regulations on the rights of its clients and their families.

This case, moreover, illustrates the need to make reforms to the DDS-probate court system that ensure that clients and families are treated fairly and their rights and wishes are respected. Among the reforms we have proposed are the following:

  • Passage of legislation requiring probate court judges to presume that family members are suitable guardians of persons with intellectual and developmental disabilities.
  • The provision of free legal assistance to family members and guardians who been barred from contact with their loved ones in the DDS system or who have otherwise faced retaliation from the Department or from providers.
  • The provision of free legal assistance to family members whose guardianships are challenged by DDS.
  • A policy statement by DDS that the Department will make every effort to comply with the federal Developmental Disabilities Assistance and Bill of Rights Act, and, in particular, the statement in the law that individuals with developmental disabilities and their families are “the primary decision makers.”
  • Increased financial oversight of the corporate provider system and the DDS/probate guardianship system.

Without reforms such as these, we are afraid cases such as this one will happen again and again.

Movement to replace guardianship appears based on little research

November 7, 2018 3 comments

A juggernaut of support has been building in Massachusetts and around the country to replace guardians of persons with developmental disabilities with more informal “support networks” of advisors.

Yet, the growing movement behind “Supported Decision Making” (SDM) appears to be primarily ideological, and little research appears to have been done on the impact of SDM on disabled individuals and their families.

Under SDM, individual guardians are replaced by teams or “network supporters,” who enter into written agreements with disabled individuals to “help them make decisions” about their care, finances, living arrangements and other areas.

Proponents of SDM claim that it restores the right of disabled and elderly persons who are under guardianship to make their own life decisions with help, if needed, from networks of supporters. That right has been overly curtailed by guardians, the SDM proponents maintain.

Even the United Nations Convention on the Rights of Persons with Disabilities included language in 2008 “that embraces supported decision-making and which is seen by some as requiring nations to adopt supported decision-making mechanisms,” according to a 2013 article on SDM in the Penn State Law Review.

Still, not everyone is convinced that all guardianships should be terminated, or that they should be replaced by SDM. As that same law journal article by Nina A. Kohn, Jeremy A. Blumenthal, and Amy T. Campbell, noted, “…despite much rhetoric touting its (SDM’s) advantages, little is known about how supported decision-making processes operate or about the outcomes of those processes.”

Without more information, the 2013 article stated,

…it is impossible to know whether supported decision-making actually empowers persons with cognitive and intellectual disabilities. Furthermore, there is reason to be concerned that supported decision-making might actually have the opposite effect, disempowering such individuals or making them more vulnerable to manipulation, coercion, or abuse.

COFAR has raised concerns about SDM, contending it could marginalize family members as decision makers in the care of their loved ones with developmental disabilities. COFAR has also raised a concern that SDM networks can potentially include service providers – a situation that would appear to pose a conflict of interest if the provider is also providing services to an individual for whom it is participating in an SDM network.

In Massachusetts, the state Senate included a provision in the state’s Fiscal 2019 budget last spring for a commission to study replacing guardianship in the state with SDM. (S.2530). While such a study would ordinarily be welcome, the proposed study commission under the budget legislation appeared to be comprised primarily of SDM supporters. And while the study was not included in the final state budget, its proponents will no doubt keep trying to insert a similar study commission in future budgets.   

The SDM study commission would have included representatives from the Arc of Massachusetts, the Center for Public Representation, and other SDM proponents, including Mass. Advocates Standing Strong and the National Association to Stop Guardianship Abuse.

COFAR would support a commission to study SDM. But it should be an impartial study, and not dominated by anti-guardianship organizations.

Massachusetts also appears to have been moving in the direction of SDM in recent years with the adoption of “person-centered planning,” a process that also appears to lack oversight and to have the potential to put much of the decision-making power over an individual’s funds into the hands of private companies.

Yet, even major legal organizations such as the American Bar Association appear to have made up their minds in favor of SDM; and like many other SDM proponents, the ABA appears to be basing its position on ideology rather than research or clinical standards.

In email exchanges with COFAR in September and last month, Dari Pogach, an attorney with the ABA’s Commission on Law and Aging, implied that a guardian may not be necessary even for some persons with severe or profound intellectual or developmental disabilities.

Pogach stated that the decision to replace an individual’s guardian with an SDM network should be based on the person’s ability make their own decisions. Yet, no clinical diagnosis or standard of cognitive ability is necessary to make that determination, she wrote.

The paradox of SDM

The view that no clinical diagnosis is needed in determining whether an individual is capable of making their own decisions appears to be linked to the ideological position of many SDM proponents that virtually all persons, no matter how cognitively impaired they might be, are capable of making life decisions.

Yet, in their Penn State Law Review article, Kohn et al. pointed out that:

…there is a potentially unavoidable paradox in acknowledging that a person has diminished decision-making capacity but maintaining that he or she is nevertheless capable of meaningfully contributing to decision-making discussions and that the decisions that result from such discussions reflect his or her wishes. (my emphasis)

Kohn at al. included the following quote from a 2009 discussion paper on SDM issued by the Office of the Public Advocate in Victoria, Australia:

Can a person be assisted through information, emotional support or in some other way to make their own decisions if they do not have, for example, an appreciation of the significance of the decision they are making or a reasonably consistent set of values? 

Lack of research on outcomes of SDM

In their article, Kohn et al. said they had found no research “evaluating the quality of decisions reached using supported decision-making.” Such research is needed, and should include whether a decision increases an individual’s welfare in some way, they wrote.

Similarly, Kohn et al. stated that there has been little or no research on the demographics of guardianship and SDM. It is unknown, for instance, how many people in the United States are subject to guardianship.

While researchers have estimated that approximately 1.5 million people in the United States are subject to guardianship at any given time, Kohn et al. stated, the actual numbers are unknown, in part, because many states fail to provide the types of records that would enable a national assessment.

Kohn et al. also stated that it is unknown what portion of persons subject to guardianship are persons with intellectual disabilities, and it is unknown what percentage of guardians are “public guardians,” as opposed to family members, friends, or other third parties. It can be reasonably assumed, they stated, that most guardians are not public guardians.

To that extent, it would appear to us that SDM is primarily aimed at replacing family members of persons with developmental disabilities as guardians.

Kohn et al. further noted that research is needed on who does best at helping a developmentally disabled person to reach a “beneficial decision.” Is it family members, friends, health-care providers, or others?

Our experience has been that family members make the best guardians, and, as noted, that there is a potential conflict of interest in allowing providers to assist developmentally disabled persons in making decisions.

In fact, Kohn at al. stated that:

…when we turn to more informal arrangements such as supported decision-making, which may occur in private and with less accountability, the potential for financial or other abuse likely increases. However, data do not seem available on the incidence of such abuse in the supported decision-making context. (my emphasis)

No distinction drawn between people with different levels of disability

The Kohn article raised an additional concern that although SDM is often seen as particularly likely to benefit persons with intellectual and developmental disabilities, “a fundamental concern with these demographic data (about SDM) is that it is unclear how representative they are of individuals with ID (intellectual disability).”

Yet, even the Kohn article did not appear to fully acknowledge or recognize that people with the same type of intellectual disability may have different reactions to SDM and to guardianship depending upon the level or severity of their disability.

For instance, the Kohn article suggested that research is needed to probe whether SDM might lead to “coercive discussion processes or even abuse that might vary with the principal’s age group or type of disability.” But the article did not question whether such variations might be due to a person’s level or severity of disability.

That is an important distinction, in our view, because it would seem that SDM might work well for persons with very mild levels of intellectual disability, but would not work well with people with severe or profound levels of that same type of disability.

In sum, we think legislators, courts, and other policy makers need to slow down when it comes to guardianship reform and think more carefully about how that should be accomplished. We have listed our own reform recommendations, which we think get at the root of the problems that guardianship does pose today.

Reform of the guardianship and probate system is needed, but that doesn’t mean the system should be replaced with something that hasn’t yet been sufficiently researched.

Committee airs testimony on sexual abuse of the disabled, but offers little indication of its next steps

November 1, 2018 3 comments

While members of a legislative committee heard testimony on Tuesday about sexual abuse of the developmentally disabled in Massachusetts, the state lawmakers on the committee gave little indication as to what they plan to do with the information.

COFAR was one of several organizations invited by the Children, Families, and Persons with Disabilities Committee to testify. The committee members asked no questions of any of the three members of COFAR’s panel, who testified about serious and, in one case, fatal abuse of their family members in Department of Developmental Services-funded group homes.

Children and Families hearing 10.30.18

Tuesday’s hearing on sexual abuse in the DDS system. The committee members asked no questions of COFAR’s panel.

COFAR President Thomas Frain, Vice President Anna Eves, and COFAR member Richard Buckley also offered recommendations to the committee, including establishing a registry of caregivers found to have committed abuse of disabled persons, and potentially giving local police and district attorneys the sole authority to investigate and prosecute cases of abuse and neglect.

The hearing drew some mainstream media coverage (here and here); but, while COFAR had alerted media outlets around the state to the hearing, most of the state’s media outlets, including The Boston Globe, did not cover it.

Committee asks no questions

Following the hearing, Frain said he was glad to get the opportunity to testify, but frustrated that the members of the committee seemed to lack interest in what he and COFAR’s other panel members had to say.

“It crossed my mind, were the committee members told not to ask any questions?” Frain said. “How divorced and disengaged is the Legislature that they can hear this testimony and not even have a follow-up question about an agency they’ve voted to fund?”

The hearing was the second since January involving testimony invited by the Children and Families Committee on the Department of Developmental Services system. The general public was allowed to attend, but not permitted to testify publicly before the committee in either hearing. The committee has given no information regarding the scope of its review of DDS.

COFAR has continued to ask for information from the committee as to the full scope of its review, and whether the committee intends to produce a report at the end of that review.

COFAR panel describes abuse and neglect

On Tuesday, Richard Buckley testified about his 17-year quest for answers to his and his family’s questions about his brother’s death in a group home in West Peabody in 2001. Buckley’s developmentally disabled brother, David, had previously been sexually abused in a group home in Hamilton, and was ultimately fatally injured in the group home in West Peabody.

David Buckley received second and third degree burns to his buttocks, legs, and genital area while being showered by staff in the West Peabody residence run by the Department of Developmental Services. The temperature of the water in the residence was later measured at over 160 degrees.

David died from complications from the burns some 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 did not substantiate any allegations of abuse or neglect.

Richard Buckley urged the committee to take action to reform the DDS system. “If nothing is done, the next rape, assault or death, will be on you,” he said. “And we will remember that.”

Buckley also read testimony from another COFAR member, Barbara Bradley, whose 53-year-old, intellectually disabled daughter is currently living in a residence with a man who has been paid by a DDS-funded agency to be her personal care attendant. In her testimony, Bradley said the man initiated a sexual relationship with her daughter, and later brought another woman, with whom he also became sexually involved, to live in the same residence.

Anna Eves discussed the near-death of her son, Yianni Baglaneas, in April 2017, after he had aspirated on a piece of cake in a provider-operated group home. The group home staff failed to obtain proper medical care for Yianni for nearly a week after he aspirated. He was finally admitted to a hospital in critical condition and placed on a ventilator for 11 days.

DDS later concluded that seven employees of Yianni’s residential provider were at fault in the matter. Nevertheless, at least two of those employees have continued to work for the provider, Eves said.

“The systems that are in place are not working and we are failing to protect people with intellectual and developmental disabilities in Massachusetts,” Eves testified. “We have to do better.”

Eves urged the committee to support a minimum wage of $15 an hour for direct care workers, more funding for the Disabled Persons Protection Commission, and passage of “Nicky’s Law,” which would establish a registry of caregivers found to have committed abuse or neglect. Such persons would be banned from future employment in DDS-funded facilities.

Eves also noted that licensing reports on DDS residential and day program providers that she reviewed — including the provider operating her son’s group home — did not mention substantiated incidents of abuse or neglect. She said Massachusetts is falling behind a number of other states, which provide that information to families and guardians.

In his testimony, Frain also urged the committee to support more funding for the Disabled Persons Protection Commission, the state’s independent agency for investigating abuse and neglect of disabled adults. Because the agency is so grossly underfunded, he suggested that the committee consider either “fully funding” the agency or “partnering with the local police and district attorneys’ offices and let them investigate” the complaints.

Frain maintained that staffs of corporate providers, in particular, face pressure not to report complaints to the DPPC, and that the agency, in most cases, has to refer most of the complaints it receives to DDS. That is because the DPPC lacks the resources to investigate the complaints on its own.

Moreover, Frain maintained, the current investigative system is cumbersome. It can sometimes take weeks or months before either the DPPC or DDS begins investigating particular complaints, whereas police will show up in minutes and start such investigations immediately.

Frain also contended that “privatization of DDS services has been at the root of many of these problems.”

Other persons and organizations that testified Tuesday included DDS Commissioner Jane Ryder, the Arc of Massachusetts, the Massachusetts Disability Law Center, and the Massachusetts Developmental Disability Council.

COFAR is continuing to urge the Children and Families Committee to hold at least one additional hearing at which all members of the public to testify publicly before the panel. COFAR has also been trying to obtain a clear statement from the committee as to the scope of its ongoing review of the Department of Developmental Services.

For a number of years, COFAR has sought a comprehensive legislative investigation of the DDS-funded group home system, which is subject to continuing reports of abuse, neglect and inadequate financial oversight.