Speaking out for People with
 Intellectual and Developmental Disabilities

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.
Audit rips Illinois' oversight of group homes for adults with disabilities
July 19, 2018

A damning state auditor general report released Thursday found systemic failures in Illinois’ licensing and oversight of thousands of taxpayer-funded group homes for adults with disabilities, problems first exposed in a 2016 Tribune investigation that documented substandard conditions and widespread harm.

The nearly 230-page report also questioned whether the state did enough in recent years to ensure the safe transition of more than 400 vulnerable adults from large developmental centers into the smaller group homes. And auditors found the state used “questionable procurement strategies” when it awarded multimillion-dollar contracts to the company managing that transition.

The audit focuses on the state’s oversight of more than 3,000 group homes — one-third of which are in Cook County — that serve about 10,000 adults with developmental and intellectual disabilities. It covers a four-year period ending June 30, 2016.

The auditors cited findings by the Tribune’s investigative series “Suffering in Secret,” which in late 2016 detailed deaths and mistreatment that occurred inside the group homes and day programs and found the public often was unaware of the tragedies because of secrecy and inaccurate reporting. Tribune reporters identified 1,311 cases of documented harm dating back to summer 2011 — hundreds more cases than the state had publicly reported. In response, state officials retracted erroneous reports and promised widespread reforms.


The Auditor General’s Report is available online: https://www.auditor.illinois.gov/Audit-Reports/Performance-Special-Multi/Performance-Audits/2018_Releases/18-CILA-Perf-Full.pdf

New Jersey
Murphy Administration Demands Action from Major Group Home Operator after Safety Problems Revealed
August 9, 2018

Gov. Phil Murphy's administration has halted new admissions at New Jersey's largest group home operator for people with developmental disabilities and demanded "immediate correction of all concerns" involving safety and staffing shortages uncovered in 18 months of inspections. The state Department of Human Services intends to appoint an independent monitor and to continue random unannounced inspections at all 62 properties operated by for-profit Bellwether Behavioral Health, state Department of Human Services spokesman Tom Hester said.

According to the report, Bellwether homes in Branchburg in Somerset County drew 156 rescue squad calls over two years, including seven involving employees accused of assaulting residents. Police are routinely called several times a day to intervene when staffing is low, the report said.

In addition to having the largest capacity of any group home provider in New Jersey, at 494 beds, Bellwether has also recorded the largest number of allegations of abuse and neglect. According to state data from March 2017 to March 2018, the state investigated 71 complaints, and substantiated 33. Six residents were repeatedly victimized, the data said.


Woman with Autism Allegedly Forced to Eat Mom’s Ashes
July 31, 2018

The physical and psychological abuse of a woman with autism held captive for a year in Tangipahoa Parish included forcing her to eat both dog feces and her mother’s ashes, attempted sex trafficking and numerous beatings, according to charges issued late last week against five Amite residents in federal court in New Orleans.When deputies found the 22-year-old woman, identified in the court documents only as D.P., June 30, 2016 she was malnourished, covered in insect bites and living in a 6-by-8-foot chicken-wire cage outside a Rushing Lane home in Amite.

The arrests of Raylaine Knope, 42, and Terry J. Knope II, 45, who are married, and their three adult children were announced a week later by the Tangipahoa Parish Sheriff’s Office.

Investigators said the abuse started after the death of D.P.’s mother, when the 22-year-old had moved to a mobile home at 57509 Rushing Lane in August of 2015. D.P. is related to Raylaine Knope, according to court records.

Terry Knope became the payee for D.P.’s Supplemental Security Income payments, which she received because of her disabilities. Before his arrest, he had received $8,796 in SSI payments that he was supposed to use exclusively for D.P.’s living expenses. Prosecutors allege he kept the money for himself. The family initially allowed D.P. to sleep on a mattress on the floor of the home, but then moved her to a shed or outdoor tent, which Taylor Knope and Jody Lambert locked every night, prosecutors said. In the spring of 2016, the family then built a cage out of chicken wire and a plastic tarp, forcing her to live there.

They kept her there “to maintain control over her and to prevent her from escaping” while they forced her to do house and yard work, prosecutors allege. If she didn’t complete the work to their satisfaction, Raylaine Knope and Terry Knope would not give her food, court documents say.

At one point, Raylaine Knope forced D.P. to dump an urn of her mother’s ashes into a bowl of milk and eat them with a spoon, prosecutors said. The family watched and laughed as she then vomited onto the table.


Temecula caregiver shot 3 developmentally disabled men before setting home on fire, coroner records show
June 22, 2018

A drunken James Steven Jennex sent a text message to a friend apologizing in advance for his actions and then fired a bullet into the heads of each of three developmentally disabled men in his care before setting his Temecula-area home ablaze and killing himself with a .357 revolver blast to the head.

The fire, on Aug. 29, 2016, at the Renee Jennex Small Family Home, killed a fourth developmentally disabled man and burned all five people beyond recognition. Investigators pulled a gas can from the rubble.

Those facts, never before revealed by the Riverside County Sheriff’s Department, were included in autopsy reports obtained from the Coroner’s Office by this news organization through a Public Records Act request.


Lawsuit Claims Caregivers forced developmentally disabled Missouri man to fight to the death
June 1, 2018

A developmentally disabled Missouri man was forced to fight another man for the “amusement” of people who ran the private care home where he lived and was left to die in a bathtub from injuries he suffered in the clash, his mother has alleged in a lawsuit.

Carl DeBrodie in a photo from a missing person's flyer. The body of the developmentally disabled Missouri man was found in a concrete-encased container in the Fulton area on April 24, 2017.

Carolyn Summers, the mother of Carl DeBrodie, 31, also alleges in the lawsuit filed Tuesday that government agencies responsible for her son didn’t provide required care and didn’t check on DeBrodie for months. DeBrodie’s body was found in April 2017 encased in concrete in a container inside a storage area, months after he went missing.


NATIONAL: Joint Report from U.S. Department of Health and Human Services’ Office of Inspector General (OIG), Administration for Community Living (ACL), and Office for Civil Rights (OCR):     January, 2018.                “Ensuring Beneficiary Health and Safety in Group Homes Through State Implementation of Comprehensive Compliance Oversight”

This report, released by three agencies operated by the U.S. Department of Health and Human Services, acknowledged the systemic shortcomings in protecting residents of HCBS waiver group homes from incidents of abuse and neglect. OIG found that up to 99 percent of these critical incidents were not reported to the appropriate law enforcement or state agencies as required. The report stated, “Group Home beneficiaries are at risk of serious harm. OIG found that health and safety policies and procedures were not being followed. Failure to comply with these policies and procedures left group home beneficiaries at risk of serious harm. These are not isolated incidents but a systemic problem – 49 States had media reports of health and safety problems in group homes.

OIG highlighted the lack of reporting critical incidents of abuse and neglect in privately operated group homes, including “deaths, physical and sexual assaults, suicide attempts, unplanned hospitalizations, near drowning, missing persons, and serious injuries. Critical incidents requiring a minor level of review generally include suspected verbal or emotional abuse, theft, and property damage. For critical incidents that involve suspected abuse or neglect, the HCBS waiver and State regulations also require mandated reporting.” It found that in the states under study, “the State agencies did not comply with Federal waiver and State requirements for reporting and monitoring critical incidents involving Medicaid beneficiaries with developmental disabilities.”

For more information on the Joint Report: https://www.acl.gov/aging-and-disability-in-america/joint-report-ensuring-beneficiary-health-and-safety-group-homes

Download the report here: https://www.vor.net/images/stories/2017-2018/ACL-group-homes-joint-report.pdf

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