Repeat violations threaten shutdown of 13 state-run group homes



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Posted on October 18, 2012 at 9:45 PM

Updated Friday, Oct 19 at 11:16 AM

A pattern of broken laws meant to keep disabled citizens in the state of Washington safe has led to the potential shut down of 13 state run adult group homes in King County.

The KING 5 Investigators have obtained state records showing the regulatory arm of the Department of Social and Health Services (DSHS) has put King County SOLA (State Operated Living Alternatives) on a short leash. The SOLA homes are now operating under what is called a “provisional certification”.  That means administrators have 90 days to prove they can keep the 50 vulnerable adults who live in the homes healthy and safe, or face a shutdown of the program.

There are 38 SOLA homes in the state which care for 130 clients. The homes are located in Tacoma, Bremerton, Yakima, Spokane and Seattle. They are unique in that they aren’t simply licensed by the state to operate as a group home; they are managed and run by state employees. The provisional certification only applies to the King County program.

The action was taken on July 19, 2012 after homes were repeatedly cited for “serious deficiencies determined to jeopardize client’s health, safety and/or welfare”.  The problems range from repeatedly leaving hazardous chemicals unlocked to failing to keep a vulnerable client safe from sexual assault.

Sexual assault case

Regulators found staff and managers broke mandatory reporting laws at a SOLA home in North Seattle in 2010, which led to the further sexual assault of a developmentally disabled client. On January 22, 2010 the female client told two SOLA workers she was being sexually abused by a male staff member who worked the early morning shift in the home. Instead of following DSHS policy and state law which mandate acting on the accusations immediately, the workers waited until their shift was over to make a phone call.

At 11:30 pm they reported the allegations to their supervisor. The manager said “she would handle it”. But she waited as well. Instead of calling police or the enforcement division of DSHS, the manager allowed the suspected rapist to show up for his morning shift as usual.  Because of the allegations she relieved the staff member of his duties an hour after his shift began. According to the disabled client, that was too late. On January 23, 2010 the client reported she’d been raped by the man again that morning.

“The manager failed to act to protect the client, thus allowing the accused staff member the opportunity to sexually abuse the client again,” wrote DSHS investigators. A state investigation also found the front line workers were confused about their obligation to report suspected abuse. “Staff report a lack of direction and demonstrated confusion regarding the appropriate entity to contact to report abuse.  It is found that the provider failed to adequately train staff in abuse/neglect reporting requirements under (state law).” wrote the regulators.

“These look like systemic problems to me,” said Bonny Oborn, a former DSHS manager who helped to develop the original SOLA program model in the 90’s. “There’s got to be a clear understanding about reporting. I would have gone over there myself, immediately. I don’t care what time it was,” said Oborn.

Assault case

In 2011 DSHS investigators found SOLA management put clients and staff at risk of harm by failing to adopt a legally mandatory safety plan for a disabled client with mental problems at a home in Shoreline. They issued a citation after it was discovered the client had bit, hit, slapped and kicked staff and other clients in the last year. The client had a history of assaulting roommates and took psychoactive medications.  According to state law, “the service provider must develop, train to, and implement (a support plan) when the client takes psychoactive medications.” Regulators found that in 18 years in the system, the client never had the mandated plan. “This failure placed all clients at potential risk of harm,” wrote state investigators.

Neglect case

This year a medically fragile client with swallowing problems was rushed to the hospital after he ate wall plaster from the SOLA home’s living room. Sources close to the investigation say the man was malnourished and that proper procedures were not in place to make sure his nutritional and medical needs were met. After returning to the King County home in September, investigators determined the SOLA program failed the man again, and broke state neglect laws, by repeatedly ignoring his medical needs That led to tremors, extremely low levels of oxygen and further hospitalization.  Again, all staff didn’t receive the required training to take care of the client.

“The provider trained most but not all staff regarding the tube feeding, medication administration via tube, administration of inhalant medications…and use of a pulse oximeter,” wrote investigators. “Based on observation, interview and record review, the provider failed to ensure necessary physician ordered supplies, medical equipment and staff training were in place upon and after a client’s return home from a nursing home. This neglect resulted in significant harm to the client including medical complications and hospitalization,” wrote the regulators.

2006 drowning

The KING County SOLA program has been under pressure before. In 2006 a developmentally disabled woman with a violent seizure disorder, Justine Booth, drowned in the bathtub at a SOLA home in Kent. A state investigation showed the caregivers were negligent because Justine’s safety plan required vigilant oversight during bathing. Instead, the staff members left Justine alone and then failed to properly administer medical help when they found her unconscious in the tub.

Justine’s mother, Loraine Campbell, had hoped her daughter’s death would serve as a wakeup call. Upon hearing about the latest deficiencies in the very same program that failed her daughter, she worried her daughter may have died in vain.

“If I could say she had a life path of sacrifice, and her life path was honored and now her death has caused other people to be safer, I’m more at home with that then—it didn’t matter. It’s just another incident, swept under the rug,” said Campbell. “That’s hard to take. That’s hard to live with.”

Agency response

DSHS spokespeople tell KING 5 the agency has made changes to the program “to ensure the high quality of care provided to the majority of our clients is consistent across the state”. Improvements include:
•    Completed risk assessments on each resident.
•    Directed that SOLA staff be retrained on behavior support policies.
•    Conducted site reviews in all King County SOLA homes.

DSHS also says the agency has held people accountable.
•    The accused caregiver and supervisor in the sexual assault case were fired.
•    The program Administrator, Robbie Rigby, was reassigned last month. All of the incidents detailed in this report occurred on her watch. Rigby has been reassigned by DSHS and now works as a fair hearings coordinator for the agency in Everett.