Audit finds serious deficiencies in Ridge administration's oversight of group homes

Commonwealth of Pennsylvania

Harrisburg, Pennsylvania 17120

717-787-1381

News Release

Audit available at www.auditorgen.state.pa.us

MOON TOWNSHIP (May 8)--A performance audit of the Commonwealth's oversight of group homes for the mentally retarded in western Pennsylvania has found serious deficiencies that threaten the health and safety of residents, including allegations of abuse and unexpected deaths that were not investigated promptly, direct care workers with criminal backgrounds, and inadequately trained caregivers.

"These findings will be of particular concern to families that have entrusted the care of their loved ones to group homes," said Auditor General Robert P. Casey, Jr. "But they should also outrage public officials and taxpayers who provide hundreds of millions of dollars each year to mental retardation services with the expectation of vigilant state oversight."

In addition to numerous audit findings, Casey's audit report offers 47 recommendations to improve the Ridge administration's oversight of group homes and, ultimately, the quality of care provided to group home residents across Pennsylvania.

"Although the Department of Public Welfare has agreed to implement many of our recommendations, it had difficulty acknowledging several deficiencies we identified, and repeatedly offered indefensible excuses for its lax oversight," Casey said.

Casey's audit, which examined the Pennsylvania Department of Public Welfare's (DPW) oversight of eight group homes in Allegheny, Beaver, Fayette, Washington, and Westmoreland counties from July 1, 1994, through June 30, 1999, focused on four areas: 1) unexpected deaths and incidents of abuse; 2) staffing issues that affect the health and welfare of group home residents; 3) the quality of service provided to residents; and 4) the physical condition of the group homes.

Casey's audit found that DPW failed to investigate three of four unexpected deaths at the time they occurred and, in two cases, uncovered serious problems later.

• A woman with no history of respiratory problems died of pneumonia. Neither DPW, the county, nor the provider agency investigated for two years. DPW finally investigated after three more deaths occurred at group homes operated by the same provider agency.

• A man died after choking on food that was improperly prepared for him at his day program. The group home provider was found negligent because there was no documentation to show that the group home had ever conveyed the man's specific feeding instructions to day program personnel. DPW did not investigate until one year after the man's death.

• A man choked to death after being given dry toast to eat by a caregiver who failed to follow the proper feeding techniques. When DPW finally investigated - two years later - it suggested that the death may have been caused by provider negligence and referred the case to the Attorney General.

• DPW allowed staff of the group homes' provider agencies to perform abuse investigations even if they had no special training to do so.

• Better train direct care workers;
• Require timely reporting of abuse;
• Promptly investigate unexpected deaths;
• Train agency staff investigators;
• Require the involvement of independent officials; and
• Better oversee the completion of investigations.

As a result of Casey's audit findings and subsequent recommendations, DPW is significantly revising and improving its reporting requirements and investigation procedures following unusual incidents and deaths. According to DPW, its new system will include standard definitions, standards for conducting investigations, required training for those who conduct investigations, and maintaining information to allow for analysis of incidents over time to detect trends and patterns that require intervention.

"DPW has an obligation to provide an aggressive and effective licensing inspection process," Casey said. "Unfortunately, we found that this process was frighteningly insufficient to ensure the quality of the direct care workers being hired by group homes."

Particularly disturbing is that Casey's audit found that state law and regulations requiring criminal background checks for prospective group home employees fail to protect group home residents.

"This is compounded by the fact that DPW's licensing inspectors don't review all employees' required criminal history reports to see if they are allowed to be working in a group home," Casey said.

Casey's review of criminal history records for a sample of 206 direct care workers found that group homes had hired 23 workers with 62 criminal convictions. Their crimes included aggravated assault; theft; forgery; solicitation to commit sodomy; prostitution; receiving stolen property; drug felonies; and robbery.

One worker with 27 criminal convictions had direct contact with group home residents for 2 1/2 years. Three DPW inspections failed to detect or discourage the employment of this worker. "Even more alarming," Casey said, "is the fact that even though we notified DPW of this employee's criminal background in May 1999, he was allowed to continue working at the group home until February 2000, in violation of state law."

Casey's audit also found that 75 percent of job applicants who were convicted of crimes stated of their employment application that they had not been convicted of a criminal offense. All of these applicants misrepresented their backgrounds and all were hired. Furthermore, 61 percent of the newly hired employees who had criminal histories were still on the job beyond the 30-day provisional period during which their criminal histories are supposed to be checked and evaluated.

"It is unconscionable that caregivers with serious criminal backgrounds can work directly with vulnerable men and women for any period of time," Casey said. "We must reinforce the need for child abuse and criminal background checks and eliminate provisional employment for those who care for the mentally retarded.

"We could better protect residents - without adversely impacting the staffing decisions of group home operators - if the Commonwealth would just commit to an expedited process for obtaining criminal background checks from the Pennsylvania State Police and the FBI," Casey said.

In its response to this audit finding, DPW accused the Department of the Auditor General of going "beyond a determination of the Department's compliance with current statutes and regulations."

In response, Casey said, "This performance audit, by its very nature, goes beyond a compliance audit and offers recommendations that will improve oversight, rather than just verify whether current laws are being followed. These are people's lives we're talking about. If DPW would implement our recommendations, it could better ensure that group home residents are safe and receiving the best possible quality of care."

Casey's audit also found that:

• DPW failed to provide guidance to provider agencies regarding compliance with criminal history background check requirements.

• Excessive turnover resulted in a lack of consistent direct care for group home residents.

• DPW regulations are not stringent enough to ensure that direct care staff are adequately trained.

• DPW did not ensure that direct care workers met regulatory training requirements.

• Not trained in abuse prevention;

• Not trained in seizure recognition and treatment for an average of 249 days, although several residents in each of the eight group homes had been diagnosed with seizure disorders;

• Not trained in CPR and Heimlich techniques, although residents in seven of the eight group homes were on specialized feeding regimens to reduce their risk of choking; and

• Not trained in crisis prevention.