Private facilities are not held accountable

By Carolyn Tuft and Joe Mahr
ST. LOUIS POST-DISPATCH

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

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

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

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

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

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

Among the findings:

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

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

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

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

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

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

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

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

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

Fewer checks, more paperwork

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

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

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

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

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

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

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

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

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

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

One of them was Oheim.

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

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

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

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

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

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

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

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

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

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

But it's clear that the problems have continued.

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

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

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

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

Not getting reports

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

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

That's if the numbers are accurate.

In a report released last fall, the state auditor's office found "numerous examples" of incidents not being entered into the state's incident tracking system - either by private facilities not submitting reports, or by regional center staff not entering them into the computer. It was a follow-up report to the earlier review by the state auditor's office, which found caseworkers at one regional center threw away incident reports before they could be entered into the tracking system and investigated. Left in the void are investigations that never happened, such as the case of Matthew Mell.

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

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

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

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

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

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

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

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

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

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

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

The lack of reporting doesn't surprise Patricia Campbell.

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

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

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

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

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

Not investigating

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

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

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

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

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

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

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

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

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

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

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

No punishment

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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