Speaking out for People with
 Intellectual and Developmental Disabilities

Your Legal Right To An Intermediate Care Facility

Right To Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID)

Individuals who qualify for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID)* under Medicaid have a legal right to such facilities for as long as they remain eligible and choose to do so. Despite a deinstitutionalization effort by those opposed to congregate care, the ICF/IID program remains a legally enforceable federal entitlement under Medicaid. States which have included ICF/IID in their Medicaid State Plans, but instead offer only Waiver services, are in violation of federal Medicaid law.

VOR's Abuse and Neglect Document

VOR's Ongoing Document:
 Updated October 3, 2019
 This document provides a bibliography of investigative media series, state audits and peer-reviewed research in more than half the states that detail systemic concerns with regard to quality of care in community-based settings for persons with developmental disabilities. Tragedies range from physical, emotional, and financial abuse, neglect and even death. Many of these outcomes are associated with a zest to move to a "community for all" vision people with developmental disabilities without adequately considering the ramifications of separating vulnerable people from specialized care and then doing away with a critical safety net (a/k/a deinstitutionalization). The lessons learned from more than 25 states should cause policymakers and lawmakers to take pause and recognize that a range of needs requires a range of service options.

Guardianship Links

VOR continues to support the rights of parents, family members, and concerned individuals as legal guardians of individuals with intellectual and developmental disabilities. We have collected some of our current and past documents here for your convenience.

VOR Survey: Giving a Voice to Families and Guardians of Individuals with Intellectual and Developmental Disabilities in Various Residential Settings

Policy favoring deinstitutionalization has had a major adverse effect on many individuals, with a shift in funding priorities from Medicaid Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICFs/IID) and other specialized facilities, to smaller service options, such as Medicaid Home and Community-Based Services (HCBS) settings.

Widespread Abuse, Neglect and Death in Small Settings Serving People with Intellectual Disabilities - 2018 to 2019

Media coverage highlighting the increasing need for more effective federal and state protections in the ever-expanding community system of care for people with intellectual disabilities.
Report: Deaths, Lack of Housing Plague Georgia System for Disabled, Mentally Ill 
The Augusta Chronicle - August 26, 2019
An independent reviewer found that despite Georgia’s claims of compliance, a state health care system for the developmentally disabled and mentally ill is still inadequate.
Georgia claims it is in compliance with a settlement with the federal government to improve the care of those with developmental disabilities and mental illness, but an independent source found their death rate is climbing and that the state still failing to meet its responsibility to house thousands suffering from these disorders.
Earlier this year, the state twice asked the Justice Department to find it had complied with and should be released from a 2010 settlement over its treatment of the developmentally disabled and mentally ill in its care. But in her report to the U.S. District Court filed last week, independent reviewer Elizabeth Jones found a number of areas where the state was lacking and in fact doing worse than in previous years, particularly with the deaths of developmentally disabled patients in community care.
An Augusta Chronicle investigation in 2015 found nearly 1,000 deaths among those patients in community care in both 2013 and 2014, and the state has twice halted moving them from state hospitals into community care over the lack of adequate care among those providers. In its last Annual Mortality Review that covered fiscal year 2017, Jones noted that the death rate has continued to climb each year, from 12.5 per 1,000 in fiscal year 2015 to 16.4 per 1,000 in 2017.
“Perhaps most significantly,” Jones notes, the death rate for those the state has already identified as high risk is anywhere from twice to four times as high.
National (Administration for Community Living)
Government Report Finds Living Centers For People With Disabilities Have Not Conducted Inspections In Years
Forbes - August 14, 2019
The U.S. Department of Health and Human Services (HHS) of the Office of Inspector General (OIG) released a report that reveals that the Administration for Community Living (ACL) has not conducted its required oversight of independent living programs for the last five years.
Americans with disabilities often face severe obstacles in life, such as getting a job, finding adequate transportation methods and living independently at home. Therefore, these independent living service programs play an integral role in bridging the gap between the inaccessibility of society and the livelihoods of people with disabilities. If the systems that are supposed to support them do not do their due diligence, then this already disadvantaged population is left even more vulnerable. 
Since July 2014, the ACL has been regulating two separate independent living programs: the Centers for Independent Living and Independent Living Services. These programs aim to support the independence of people with disabilities nationwide by providing tools, resources and support for integrating the disability population fully into their communities. Services rendered by these programs include providing discretionary grants to nonprofit organizations and improving nursing homes and other assisted-living institutions. 
Under section 706(c)(1) of the Rehabilitation Act of 1973, which governs both programs, the ACL must conduct onsite compliance reviews of at least 15% of the Centers for Independent Living programs that receive funds under this law. Without these congressionally mandated site reviews, program funds are vulnerable to fraud, waste and abuse. 
Upon receiving a hotline complaint in June 2017 alleging that the ACL was not conducting required oversights, the HHS of the OIG conducted an audit of 284 Centers for Independent Living and two Independent Living Service programs that receive federal grants from the ACL. The department was not aware that the onsite inspections were not being conducted until the receipt of the hotline complaint. 
The ACL was appropriated $156.6 million for independent living program services during the audit period of October 1, 2015, through September 30, 2017. Although the ACL awarded $151.5 million to grantees for independent living program services, it did not allocate sufficient funds from the remaining $5.1 million to support onsite compliance reviews. 
$4.5 million lawsuit alleges abuse of developmentally disabled man at state-licensed group home
The Oregonian - August 11, 2019
In September 2014, Margaret Lamb dropped off her 21-year-old son at a green, one-story house in Gresham with mixed feelings.
She knew her son required more care than she could provide as a working single mother. She hoped the state-licensed group home for developmentally disabled adults would provide Matthew Lamb with the specialized attention he needed.
But she didn’t realize she would spend the next four years trying to get him out.
She’s now suing the company that operated her son’s group home as well as Multnomah County and the state of Oregon, alleging they failed to care for Matthew Lamb, protect him or properly investigate her complaints about his treatment. The suit seeks up to $4.5 million in economic and noneconomic damages.
13 Investigates uncovers pattern of abuse, neglect in group homes for the disabled
WTHR-TV13 - July 29, 2019
Indiana's most vulnerable residents are often cared for in group homes with round the clock staff. No one disputes it can be a tough job, but when you have an industry with high turn over rates and improperly trained workers, group homes can become places of extreme abuse.
13 Investigates' Sandra Chapman uncovered troubling issues for a provider with a network of group homes across the state and the country. One of these group homes is in a house located on Atwood Court in Fishers. The home is operated by ResCare, one of Indiana's largest residential care providers, and is where Indiana's most vulnerable are supposed to be protected.
Records show that protection wasn't extended to Anthony Harris who lived at the ResCare group home in Fishers. Harris has cerebral palsy and is completely disabled and non-verbal.
A caregiver admitted to viciously beating Harris in 2017.
Emergency workers found Harris bloodied, beaten and, according to his attorney, tortured inside his room. He suffered all of the injuries at the hands of Michael Anderson, the man ResCare hired to care for him.
Emergency room nurses from Community Hospital were the first to alert police.
In a 911 call obtained by 13 Investigates, a nurse tells the dispatcher: "His face is all bruised up. His eye is swollen and the CAT scan, it seems like he might have been abused in the group home or somewhere. And there's another patient that came from the same group home, same situation. His face is all bruised up," she said, referring to Harris' roommate who was also attacked.
"There was blood everywhere. It had been splattered. It was a horrific scene," said Scott Benkie, the Harris family attorney.
Missouri reaches more than $1 million settlement in disabled man's death
KSHB-TV41 - July 26, 2019
After the death of a developmentally disabled man in Missouri's care, the state has paid more than $1 million to settle a federal lawsuit.
Carl DeBrodie's badly decomposed body was found in a garbage can encased in concrete in a Fulton, Missouri, storage locker in April 2017.
DeBrodie, 31, had been staying at Second Chance Homes, a Fulton facility contracted by the Missouri Department of Mental Health's Division of Developmental Disabilities.
"They went through that provider enrollment process, and then they were basically out there and could start making themselves available for families and guardians to select as a provider," said Valerie Huhn, director of the Division of Developmental Disabilities. The money to pay for providers such as Second Chance Homes comes from both federal and state tax dollars.
According to the now-settled federal lawsuit and ongoing criminal cases, Second Chance Manager Sherry Paulo and her husband, Anthony Flores, had DeBrodie fight another client for their amusement.
"We want the person or whoever done this to my son to pay," said Carolyn Summers, DeBrodie's mother.
Those court records also say that in the fall of 2016, DeBrodie had a seizure from his injuries in those fights.
Flores and a client placed DeBrodie in a bathtub and turned on the shower in an effort to get him to snap out of it, according to court records.
"And there was never any type of outside medical care requested or attempted to be given," said Rudy Veit, Summers' attorney in the federal lawsuit.
DeBrodie died in the bathtub.
"He stayed in that tub for a length of time until they moved him to a different location, which was a trash can," Veit said.
New York
Why New York says parents weren't told of incidents at group homes
Albany Democrat & Chronicle - July 23, 2019
The state's Office of Mental Health failed to properly notify parents of incidents of abuse at several facilities despite a law requiring timely notifications, according to a new audit from the state's Comptroller's Office.
New York adopted "Jonathan's Law" in 2007 to expand the access to information regarding allegations of neglect and physical, sexual and psychological abuse at state-operated or licensed facilities to parents, guardians and other qualified persons.
The law was named after Jonathan Carey, a 13-year-old non-verbal and developmentally disabled child from the Albany area who died while in state care in 2007. His parents made several attempts to obtain information regarding several injuries he sustained during his time at the facility to no avail.
A review of 210 incidents across eight facilities between April 2015 and Jan. 9, 2018, found 42 incidents with no evidence to support a telephone communication was ever made within the required 24-hour window, the audit from Comptroller Thomas DiNapoli found.
Some facilities also failed to provide requested information to a qualified person within the required timeframe, the audit said.
Service Provider Sued Over Alleged ‘Dickensian’ Conditions
The Baltimore Sun - July 10, 2019
A residential and educational facility for students with disabilities operated under “Dickensian” conditions, failing to provide children with required medication or appropriate supervision and attempting to cover up assaults, according to a lawsuit filed this month by the Maryland Attorney General’s office.
AdvoServ Inc. ran a program for people and students with disabilities in Delaware. Dozens of Maryland children with cognitive disabilities and mental illnesses were sent to their facilities for treatment and education after the state determined their needs couldn’t be met at home or in their local schools.
But even though the state paid AdvoServ more than $230,000 a year to care for each child, the lawsuit alleges their facilities failed to “provide even minimally adequate care to the children under their protection.”
Maryland ended its contract with AdvoServ in 2016. The state planned to sever ties with the company by October of that year but still hadn’t removed the 31 Maryland children in their care when a 15-year-old girl died at the Bear, Del., facility that fall.
The company — whose facilities across the country have a long and troubled history — has since changed its name to Bellwether Behavioral Trade. Representatives did not immediately return calls seeking comment.
The attorney general’s office said the state paid AdvoServ more than $13 million to care for children between June 2015 and October 2016, and is seeking to recover unspecified damages and penalties from the company.
South Carolina
SC Mental Health patient suffocated by hospital staffers who failed to follow training
The Charlotte Observer - July 14, 2019
A state Department of Mental Health patient suffocated to death earlier this year at the bottom of a dogpile of agency employees who failed to follow the department’s training on physically restraining patients.
At least three of the employees involved in the death of 35-year-old William Avant had not been trained properly, according to an ongoing probe by state health regulators reviewed by The State as part of the newspaper’s weeks-long investigation into Avant’s death.
Avant, a Georgetown, S.C., native who had been in Mental Health’s inpatient care for more a dozen years, was killed on Jan. 22 when Mental Health staffers improperly pinned him face down on a Columbia hospital floor and lay atop his back for four minutes, preventing his diaphragm from expanding to deliver oxygen to vital organs. Hospital staffers failed to check Avant’s breathing as he died beneath them, records show.
Their actions were explicitly prohibited — in red, all-capital letters — in the department’s training manual, raising questions about the agency’s management of employees, including training, and how well Mental Health cares for its 100,000 patients, including 1,500 inpatients who are some of the state’s most vulnerable residents.
New York
Judge Orders Expanded Oversight for Mentally Ill New Yorkers In Supported Housing
ProPublica - July 12, 2019  (Follow up to story appearing December 6, 2018)
Not enough people are covered by an oversight system meant to safeguard residents of a New York housing program for people with mental illness, a federal judge found this week, after reviewing a report commissioned in response to a ProPublica and Frontline investigation.
Since January 2014, more than 750 people with severe mental illness have moved out of troubled New York City adult group homes and into subsidized apartments under a federal court order. The idea was to give them a chance to live outside institutions, with services coming to them as needed through a program called supported housing.
But last December, ProPublica and Frontline revealed that more than two dozen people who had moved out struggled to live safely on their own. Many had been repeatedly hospitalized. One went missing; another was in jail. At least six had died under suspicious circumstances, and the state had only recently developed a system to track such incidents.
The story prompted U.S. District Judge Nicholas Garaufis to order a report from Clarence Sundram, the independent court monitor assigned to oversee the transition. Garaufis asked Sundram to gauge the effectiveness of the incident reporting system implemented in the summer of 2018.
New York
Residents Cowered While Workers at a Group Home Smacked and Pushed Them
The New York Times - June 9, 2019
Some of society’s most vulnerable people have long been preyed upon by abusive workers in group homes. New York vowed reforms, but they didn’t happen.
The people who worked at the brick building that housed 24 developmentally disabled residents called it the “Bronx Zoo.”
One worker regularly hit a resident while he ate, making him cower in fear at mealtimes. Another worker would repeatedly “smack, punch and push” a female resident, sometimes when she tried to watch staff members cook. A female worker sat in the lap of a male resident who used a wheelchair, placing his hands on her breasts and moving provocatively while other employees laughed and cheered, according to records and depositions.
The abuse first came to light five years ago, leading to a public outcry and an investigation by the state, which runs the facility, called the Union Avenue I.R.A., in the Bronx. But in a new review of the case, The New York Times found that when officials tried to fire 13 employees for abuse or neglect at the home, they failed each time. The workers were shielded by the state arbitration process, whose shortcomings often return abusive employees to the job.
The Bronx case is emblematic of a larger problem across New York. Hundreds of pages of disciplinary records from 2015 to 2017, obtained by The Times under the state open-records law, show that more than one-third of the employees statewide found to have committed abuse-related offenses at group homes and other facilities were put back on the job, often after arbitration with the worker’s union.
The residents in the state’s far-flung network of more than 1,000 group homes are particularly dependent on their caregivers. In many cases, they are unable to communicate and live in group homes almost their entire lives. Some are also immobile, while others have been all but abandoned by their families.
Recycling abusive employees has long been an endemic problem. Eight years ago, The Times reviewed thousands of pages of disciplinary files for 233 workers. In a quarter of substantiated abuse cases, employees were transferred to other homes rather than fired, including in cases involving sexual assaults. The newly obtained disciplinary records involved 120 employees. They show that while the transfers appear to have decreased, the state still keeps problematic workers at their jobs.
The findings are the latest sign that attempts to change the oversight of care for the developmentally disabled by Gov. Andrew M. Cuomo’s administration has stumbled.
New Jersey
Bellwether's license to operate group homes in New Jersey revoked
North Jersey Online - May 22, 2019
New Jersey will shut down the state’s largest for profit provider of residential and day programs for individuals with developmental disabilities for operational violations and failure to make needed improvements. 
Following an investigation by an independent monitor, a moratorium on admissions and a period of enhanced oversight triggered by reports of alleged operational violations at facilities statewide, Bellwether Behavioral Health will lose its licenses to operate in New Jersey, according to the state’s Division of Developmental Disabilities. 
Bellwether did act to address state officials’ concerns, and “has not been able to demonstrate the systemic improvement needed to continue operations in our state,” said Jonathan Seifried, the division's assistant commissioner.
The state report on the independent monitor’s findings released Wednesday found 12 of Bellwether’s 14 group homes operating on provisional licenses in New Jersey were deficient in cleanliness. Half smelled of urine, five had rotten or expired food in the refrigerator and one was found to have mixed up residents’ medications, according to the report. 
Some homes had as many as 60 deficiencies, the report states.
DSHS to pay $8M after neighbors’ pleas to help vulnerable Seattle man brought no action
The Seattle Times - May 20, 2019
Vernon Gray was living with rats when a social worker showed up to his Central District home, where a layer of garbage coated the floor and a squalid odor caused people to gag when they stepped onto the property.
That was in 2009, when the state’s Adult Protective Services received its first report about him. Gray, who has a developmental disability, had been living in the house alone since his mother died in 2000. Neighbors begged the state to intervene, explaining he was unable to take care of himself. They continued after Gray became homeless in 2013.
Adult Protective Services (APS) investigated Gray’s situation three times since 2009, but each time, he was left on his own. The agency, which is within the Department of Social and Health Services (DSHS), investigates reports of vulnerable adults who have been abused, abandoned or neglected. Attorney David Moody argued in a tort claim that the state failed to protect Gray, now 64.
On Thursday, the department agreed to an $8 million settlement, which Moody said is the largest paid by the state in an adult protective services case. The state agreed to settle the case before a lawsuit on Gray’s behalf was filed.
This is the latest in a series of troubling and costly incidents at DSHS, which oversees a state mental-health system that has been stung by damaging federal and state court rulings and federal decertification of its main psychiatric hospital.
Cases of abuse, neglect of California disabled clients going unchecked: whistleblower
KTVU-TV2 - April 25, 2019
Cases involving starvation, neglect and sexual abuse targeting developmentally disabled clients in California are not being addressed thoroughly or going unchecked altogether, according to a former North Bay care employee who worked with patients.
Roberto Franco, an ex-employee of the North Bay Regional Center in Napa, said he is blowing the whistle on the multi billion dollar care industry that he believes is overwhelmed with cases and allowing serious incidents to fall through the cracks. “It’s crazy because I’ve been trying to tell people about these things I’ve seen,” he told 2 Investigates.
By law, the California Department of Developmental Services (DDS) is responsible for ensuring more than 330,000 people with developmental disabilities receive services and support. Every year, the department allocates billions of taxpayer dollars to 21 different regional centers statewide to carry out its responsibility. Those regional centers hire and pay service providers to directly house and care for clients whose disabilities include autism, epilepsy, intellectual disabilities and cerebral palsy. 
Franco was fired from the North Bay Regional Center (NBRC) in January 2018 for being “unprofessional and insubordinate,” according to his termination letter. But he believes regional center management penalized him for being persistently outspoken about client issues. As a service coordinator, it was his job to monitor client care and report problems. 
All caretakers, providers and agencies are legally required to report incidents where a client is hurt or could be hurt. These reports are processed by regional centers and DDS. 
US Senate Launches Investigation Of Group Home Provider
The Oregonian - April 3, 2019
The U.S. Senate has launched an investigation into a national corporation’s homes for people with disabilities in response to a report about substantiated abuse at one of the company’s facilities.
The Oregonian reported in January that Oregon regulators shuttered a Mentor Network home in Curry County following extensive evidence that a client with a disability had been severely neglected. State regulators found that managers repeatedly ignored caregivers’ concerns about the person’s festering pressure wound, including that it smelled of “rotting flesh.”
“When vulnerable Americans are abused or even killed in the care of a taxpayer-funded care provider, that organization must be held accountable,” Sen. Ron Wyden, D-Ore., said in a statement this week.
The Senate Committee on Finance, chaired by Sen. Chuck Grassley, R-Iowa, sent letters Tuesday to the Oregon and Iowa branches of the The Mentor Network, demanding copies of a raft of compliance records by month’s end. The company operates in 36 states, serving about 13,000 people in group homes and 19,000 in non-residential settings.
The Senate investigation comes on the heels of renewed oversight by state regulators in Oregon who have been closely monitoring Mentor Oregon since finding problems in Curry County in late 2017. This marks the second attempt by the state Department of Human Services to force Mentor Oregon to make its facilities safer for residents.
A caregiver raped two intellectually disabled women, police say. Both gave birth to children.
The Washington Post - March 2, 2019
The mission of the center in Fairfax County is to “employ and support” people with disabilities, but a prosecutor said a worker sexually assaulted a 29-year-old woman with Down syndrome in its offices.
Police began an investigation in October 2017 after a doctor made a disturbing discovery: The woman was five months pregnant, authorities said. She later gave birth.
The pattern played out again nearly a year later. Police say another client at the MVLE Community Center, a 33-year-old woman with intellectual disabilities, was raped. The case was reported to police in August 2018 after her doctor discovered she was pregnant. She also gave birth.
Last month, Bernard Betts-King, 60, a behavioral specialist at MVLE, was charged with sexually assaulting both women. DNA tests showed he was likely the father of the second woman’s child, court papers say. DNA results are pending in the other case.
Advocates say the case underscores a problem that has received less attention in the #MeToo era: the sex assault of the intellectually disabled. Numbers produced by the federal Bureau of Justice Statistics for an NPR investigation last year found those with intellectual disabilities are sexually assaulted at seven times the rate of people without disabilities.
Note: Betts-King pleaded guilty in July:
El Dorado Hills school where special-needs student died will close
The Los Angeles Times - January 22, 2019
An El Dorado Hills school at the center of an investigation over the death of a 13-year-old autistic student announced this week that it plans to close its doors permanently on Friday.
Guiding Hands School, a private school that has served students with disabilities since 1993, made headlines when a student, identified as Max Benson, died after being placed in a face-down restraint by school staff in November. The California Department of Education said the boy was held down for an hour and 45 minutes, according to Sacramento Superior Court records.

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