The Oregonian

An Oregonian Special Report

After Fairview

How Oregon fails disabled adults

Caregivers have mistreated one in five developmentally disabled clients since 2000, and Oregon officials are slow to make the homes safer
By Michelle Roberts - Published November 4, 2007

The 9-1-1 operator asked the question several times: Is she breathing?

David Pape, the woman’s caregiver, didn’t hesitate.

“Yes, she’s breathing,” he said. “And she’s warm.”

But when paramedics arrived at Pape’s foster home seconds later, they found quite a different scene: Natasha Thomas, 25, lay dead in an empty bathtub. Her body, stiff and blue, had begun to decompose.

Pape told authorities that he’d tended Thomas through the night and watched her get up that morning.

Questioned by police, Pape eventually admitted he was lying. As an autopsy later showed, Thomas had died hours before he called for help.

The state paid Pape $18,000 a month to house and protect Thomas and three developmentally disabled roommates. The night she died in August 2005, Pape was miles away, celebrating his wedding anniversary at his second home. He had entrusted his clients to his brother-in-law, a 20-year-old former fast-food worker with virtually no training or experience as a caregiver.

When Oregon shuttered Fairview Training Center, the notorious asylum in Salem, officials had charted a very different future for people like Thomas, who had an IQ of 48. Freed from the institution, they were promised lives of inclusion and dignity with caring foster families or in small homes run by the state and charities.

For many, it hasn’t happened.

In the seven years since Fairview closed, more than 2,000 developmentally disabled adults have been robbed, beaten, raped, neglected or cursed, most often by their state-paid caregivers. Besides Thomas, at least 13 others have died after workers failed to provide necessary care.

Clients have choked on food, suffered violent injuries or become ill with treatable health problems that caregivers ignored or missed. In half the deaths investigated by the state, The Oregonian found that caregivers didn’t recognize clients’ serious health problems or act quickly enough to call 9-1-1.

One foster care worker buckled an electric dog collar around the neck of an autistic man, zapping him repeatedly to control him. Another caregiver punished a client with cold showers and attacks by her dog.

Yet another — while “employee of the month” at a Jackson County group home — sexually assaulted a mentally retarded woman who could not move or speak.

Their stories, archived in a state database and detailed in hundreds of confidential files obtained by The Oregonian, show that one of every five clients in state-licensed foster or group homes have been victims of at least one serious instance of abuse or neglect during the past seven years.

The officials who oversee Oregon’s 8,000 caregivers and 1,200 adult group and foster homes say they are working to protect clients. But the state has failed to close troubled homes, even after clients were raped or died. Officials also have been slow to adopt reforms in areas they acknowledge would make the system safer.

More than half the states use computerized registries to identify abusive caregivers and deny them jobs.

Not Oregon.

Pape lost his license to operate after Thomas died, yet he is free to work in someone else’s home.

Department of Human Services officials have known for years that they lacked legal authority to fire dangerous caregivers. But it wasn’t until this year that they asked lawmakers for permission to develop a registry or the power to use it to deny employment. They don’t plan to request funding for a registry until 2009.

The state also has dragged its feet on the 9-1-1 problem.

Records obtained by The Oregonian show that the DHS two years ago determined that caregivers weren’t promptly calling paramedics. Yet a new 9-1-1 policy has been held up because officials can’t agree on how to word it. In the interim, another resident died after caregivers delayed calling for help.

Weak financial controls also invite abuse. Oregon does not closely scrutinize how foster home operators spend the thousands of tax-free dollars they receive each month to take care of clients. State officials acknowledge that this has allowed some foster home providers to cut corners and profit from the savings. .

James Toews, a senior DHS official, defended his agency’s performance. He said the registry, an upcoming $1 an hour raise for group home workers and other efforts should make a difference.

“We’ve tried to approach how we safely support people with pretty complex needs,” Toews said. “We’ve done as good if not a better job than most states on trying to drill down on that.”

Because states define abuse and neglect differently and use varied methods to monitor it, rankings comparing them are unavailable. But Toews and others concede that Oregon’s numbers are unacceptably high.

“It’s a tragedy,” said Bill Lynch, who runs a federally financed advocacy group, the Oregon Council on Developmental Disabilities, charged with pushing policies to help people in the system.

“We really need to turn this around,” Lynch said. “This goes well beyond embarrassment.”

Life after Fairview

Oregon is not alone in its struggle with care for people with developmental disabilities.

Academic research shows that people with conditions such as mental retardation, autism and cerebral palsy are at least four times more likely to be victimized than the overall population. The abuse most often happens at the hands of those responsible for their care.

The state’s closure of Fairview marked a milestone in a decades-long shift to end the isolation of people with developmental disabilities. A federal civil rights lawsuit in the mid-1980s had laid bare abusive conditions there. Oregon spent millions to improve Fairview, then gradually moved its residents out.

Now, the state spends $134 million a year to house 4,200 residents in 611 foster homes, which are operated by individuals, and 544 group homes, which are most often run by nonprofits.

Many of the homes provide respectful care and are quick to correct deficiencies. And though state or county investigators substantiate hundreds of incidents of abuse or neglect by caregivers each year, they vary widely in severity. Neglect can range from falling asleep on the job to mistakes that result in physical harm to a client.

State officials say they have adopted broad definitions of abuse to err on the side of safety. As a result, they say, the system captures lapses that, though not insignificant, can overstate the true harm to clients.

In estimating that a fifth of group and foster home residents have been abused in recent years, The Oregonian sifted from the state’s official data minor incidents of theft and neglect, paperwork errors and all verbal abuses. Counted were physical and sexual abuse, serious financial exploitation, improper restraints and neglect that jeopardized a client’s health or safety, such as mishandling medicine.

The persistent abuse undercuts Oregon’s promise of a safe life outside an institution.

That safe life didn’t happen for a 26-year-old mentally retarded man who in 2001 was pushed to the floor, threatened with a knife, gagged and restrained with packing tape, then kicked by three group home caregivers, one of whom had a felony record. He was one of the 386 clients who suffered 463 incidents of physical abuse since Fairview closed.

It escaped a 36-year-old man with cerebral palsy who couldn’t speak but repeatedly tapped the word “RAPE” on his communication board at a doctor’s visit. His foster home operator sodomized him and fled with his rent money but never was prosecuted. The man was one of 140 clients who were sexually abused, mostly by caregivers.

It will never happen for Jack Gipson, who died in May 2003. Workers at his group home in Cornelius failed to summon help when he showed signs of respiratory distress. Records show that Gipson, 55, wheezed and coughed for three days before he collapsed and died of aspiration pneumonia, which easily could have been treated.

Gipson was one of 1,143 clients who were neglected in some manner during the past seven years, and one of the 14 deaths in which investigators substantiated maltreatment by caregivers.

For years, their stories and thousands of others lay buried in boxes at the Department of Human Services, where a small office of investigations compiles reports of mistreatment.

To assess how developmentally disabled Oregonians have fared in the new system, The Oregonian requested abuse and neglect reports along with a state database that listed every allegation investigated since 2000.

The department declined to release complete records, citing the privacy of clients. Instead, the agency provided summaries that censored details such as where abuses happened and victims’ and witnesses’ names.

To learn more, the newspaper obtained thousands of pages of unredacted reports. Those records, visits to homes and therapeutic programs, plus interviews with police, prosecutors, county caseworkers and clients helped flesh out details behind the system’s overall statistics after Fairview.

Of more than 10,000 total allegations of abuse or neglect, investigators substantiated 4,648. Those incidents involved 2,035 identified caregivers and 2,033 victims, half of whom suffered more than one substantiated abuse. On average, investigators substantiate about 600 abuse allegations each year.

Most involve residents of group homes, where abuse is more likely to be reported and corroborated because there are more staff to witness problems.

Bob Joondeph, executive director of the Oregon Advocacy Center, a nonprofit that provides legal aid to people with developmental disabilities, said the numbers reflect what’s become a “crisis-response” system. Oversight falls too heavily on overloaded county caseworkers, who under state contract handle abuse investigations and inspect and license foster homes.

The result, Joondeph said, is that clients must rely on families or others to advocate for them. “You can’t depend on the government, at least in this state, to be playing an intensive supervisory role,” he said.

Too little, too late

On July 8, 2004, Paul Crawford returned home from his part-time job because he didn’t feel well.

Caregivers at a Portland group home run by Rainbow Adult Living thought Crawford was just trying to get out of work. But any question of whether the tiny and frail 61-year-old “was feigning illness ... was obviously dispelled when he vomited a black-colored substance,” a county investigator later wrote.

Crawford’s caregivers failed to recognize it as blood. Over three days, his condition worsened. No one at the home “did so much as check his temperature,” the investigator found. It wasn’t until Crawford lost consciousness that a caregiver finally called 9-1-1. Paramedics were outraged.

Crawford “was lying in bed, full of feces, vomit and urine,” one paramedic said later. “The odor was enough to stop you in your tracks. There was urine on the floor. We almost slipped. He was lying in bed, shaking.”

Crawford had survived years at Fairview, where he’d been sent as a young man with severe brain damage from a case of measles contracted as an infant. Four days after the 9-1-1 call at Rainbow, he died of an infection from untreated pneumonia and a bowel obstruction.

“Had the patient been brought in sooner, he might not have died,” the doctor who treated Crawford later told the investigator, who ruled his death a case of neglect.

Dr. Tina Kitchen is a top DHS medical officer whose job is to review death cases. When The Oregonian asked her about Crawford’s death, she said she wouldn’t expect most caregivers to behave any differently.

“I don’t think a lot of people would recognize that as being blood,” Kitchen said. Workers were found responsible in Crawford’s death only because the agency holds providers to a “very high” standard when investigating neglect, she said.

The system’s training standards are not so high.

Getting a foster home license in Oregon is as easy as watching four, half-hour training videos and passing a short test on the contents. Licensees — but not employees — also must know first aid and CPR.

At group homes, direct-care workers must learn how to bathe and feed clients but aren’t required to know CPR or advanced skills unless they work alone. Knowledge of “core competencies,” such as how to identify medical problems and abuse, is required. But with high turnover, workers rarely get beyond the basics.

State officials say nearly seven in 10 group home workers leave their jobs within the first year. High turnover is a national problem, they point out, thanks to low wages and the difficulty of the work. It creates higher costs for recruiting and training replacements, and studies have shown it contributes to abuse.

In 2003, an outside audit concluded the state “is at risk of placing or maintaining clients in (foster) homes where the providers are not adequately trained or qualified.” The audit arrived after Oregon lawmakers, during the recession, cut spending on programs for people with developmental disabilities by about 8 percent.

To begin reversing the problem, DHS officials asked lawmakers this year for the first significant pay raise in four years for group home workers. They approved $20 million to boost average pay $1 an hour, to $10.58, starting Feb. 1.

Toews said the raise, while helpful, won’t dramatically improve the situation.

Providers have coined a term for their predicament: “desperate hiring.” Anyone who passes the required criminal background check is likely to get a job. Caregivers often come from fast-food or retail, get little training, then are expected to deal with the complex medical and behavioral needs of their clients.

Even knowing when to call 9-1-1 can be a problem. Reports show that some workers are reluctant to call paramedics in the absence of a supervisor for fear they will be blamed for problems.

Almost two years ago, a group of DHS employees recognized the problem and drafted a new policy to encourage timely 9-1-1 calls. The team submitted the document to administrators, including Kitchen, on March 18, 2006. But she and other top officials couldn’t agree on how the potentially lifesaving policy should be phrased.

It went nowhere.

About five months later, a 52-year-old group home resident died after several days of illness. Finding neglect, an investigator said the caregiver failed to call 9-1-1 despite the client’s “respiratory distress, moaning and bloated abdomen.”

DHS officials say they recently have begun discussing 9-1-1 in training sessions, emphasizing that caregivers need not check with a manager or nurse before calling paramedics in a medical emergency.

Homes stay open

Records show the state has been slow to shut down troubled homes.

Laurie Lindberg, who heads the state’s licensing unit, said that because the state is in constant need of new homes, her approach is to help providers fix problems rather than punish the homes.

“We don’t have that many facilities,” she said.

But for residents, that approach can be a gamble.

Rainbow Adult Living runs nine group homes in the Portland area. After Crawford’s death, the paramedic who complained about conditions at the home personally told county officials it should be shut down.

Instead, the home stayed open, and Crawford was exploited in death.

RaNee Osborne, the Rainbow manager on duty when he died, forged Crawford’s name on a $2,788 check issued to him a month after his funeral. She deposited it into her own checking account, licensing records show.

Investigators found that Osborne had over several years embezzled thousands from clients, treating herself to such things as a Game Boy Advance, a new TV and pink cowboy boots.

Also missing was a $5,000 check that Crawford’s 91-year-old mother, Ione, sent the home to buy other residents a gas grill in her son’s memory. Recently, Osborne told The Oregonian that the money was “disbursed to the employees who worked with Paul as a bonus.”

Last month, Osborne was convicted of first-degree theft and first-degree criminal mistreatment relating to her financial abuse of Crawford and two other Rainbow residents, whose Social Security checks she stole.

Records show DHS officials were told about the financial irregularities as far back as 2005 — and allowed the home to operate even after Rainbow executives refused to fire Osborne.

She quit on Aug. 29, 2005, after learning she was the subject of a Medicaid fraud investigation. Before she left, Osborne destroyed financial records by “tossing computer equipment out of the window at her office, intentionally breaking it on the pavement,” a Multnomah County compliance officer told the state Department of Justice.

Lindberg’s unit inspects group homes every two years. Visits are supposed to be unannounced, but Toews confirmed what providers told The Oregonian: Most get several hours’ notice, giving them time to put on a best face.

County case managers are supposed to add another layer of protection. Under their state contracts, counties must investigate abuses and visit every group and foster home at least 10 times a year. But case managers have competing duties — some also monitor as many as 100 clients — so home visits don’t always happen.

At a licensing inspection last year, months after Osborne’s exit, officials uncovered more than a dozen additional violations at the home where Crawford died. Among the infractions: failing to provide job training and financial oversight.

The state fined Rainbow $2,000 and gave the agency another chance. Lindberg said she wanted to give Rainbow, one of the oldest group home providers in the state, every opportunity to remedy problems and avoid displacing clients.

It wasn’t until March — shortly after The Oregonian asked to view the nonprofit’s file — that the state launched a new inspection of all Rainbow’s homes. Reviewers found a “systematic failure to safeguard resident funds,” and officials now plan to close four of the homes, including the one in which Crawford died.

Michael Larson, who recently took over as Rainbow’s executive director, said he’s begun new practices at the $4 million-a-year nonprofit, including financial controls and a 9-1-1 policy to “err on the side of caution.”

Rainbow is not alone. Licensing records and state data include more than a dozen group home operators with 10 or more substantiated abuse or neglect allegations.

In the Cornelius home where Jack Gipson died in 2003, problems with medical care continued, prompting two more incidents of neglect. Alarmed at the lack of state follow-up, Washington County’s top case manager, Ted Barber, wrote to Lindberg demanding action.

“It is our hope that your office will consider any avenues to ensure that enduring, corrective action occurs,” Barber wrote.

One home, 11 inquiries

Repeat offenders aren’t pervasive in the system — but neither are they rare.

An example is foster home operator Antonia Galanto, who was investigated 11 times between 2000 and 2004 and found responsible of neglect or abuse in six different cases.

In 2000, a county investigator found that Galanto overcharged clients $4,400 when she took them on a Hawaiian vacation. The next year, another report determined she had hired her brother, Francisco “Cisco” Galanto, and allowed him to use drugs at the home. Later, he was found to have paid a female resident $5 for sex.

Still another investigator in 2003 found that Galanto physically abused a 45-year-old resident by spraying him with a garden hose to punish him.

In April 2004, a final report determined that Galanto had again helped herself to her clients’ money. Authorities ultimately charged her with 13 counts of criminal mistreatment and theft, but the case was dropped on a technicality: Police waited too long to arrest her.

Galanto could not be reached for comment.

The Oregonian identified more than 200 caregivers found responsible for abuse or neglect in more than one investigation. As a group, they accounted for about a fifth of all substantiated allegations — more than 900.

The information resides in the state’s own database. But officials say they haven’t had legal power to use the data to deny employment — as do Washington and states with a registry to screen for abusive workers.

Washington officials call the system a success. Using the registry, they have denied 1,800 applicants jobs in state care systems since October 2003. The rules allow a caregiver to challenge an accusation of abuse. But once upheld, a single incident is enough to be blacklisted from any publicly financed caregiving job.

Although an Oregon registry is in the works, it is years off. State officials say they are negotiating with providers to design a system that would include appeal rights for caregivers. They don’t yet know how much it might cost, although they said Washington spends about $1 million a year on its system.

State officials examined the list of repeat offenders The Oregonian provided. Had a registry been in place here, they said, they would have blocked 74 of the listed workers from continuing as paid caregivers.

Difficult care, higher fees

After Natasha Thomas died in a bathtub at her foster home, investigators substantiated caregiver neglect. Her case shows how weaknesses in training, 9-1-1 procedures and fiscal controls can all converge.

When she failed to speak by age 5, doctors determined she was mentally retarded and deaf. Surgeons restored some hearing, but a low IQ kept Thomas from ever fully comprehending her world.

In 1997, two months before Thomas’ 18th birthday and after numerous contacts with child welfare workers, state officials removed Thomas from the home of her mother, an alcoholic.

Thomas struggled for the next several years, cycling through at least three state homes. She didn’t fit the stereotype that mentally retarded people are always sweet and mostly mute. On the contrary, Thomas smoked a pack of cigarettes a day and swore like a rap star.

But the issues that made Thomas’ care difficult also made it lucrative.

Unlike wages for most group home workers, which are set by the state, foster home providers are paid fees based on the difficulty of the client’s behavioral and medical issues. The payment for Thomas, with her unpredictable outbursts and severe asthma: $6,072.70 a month, about double the state average.

David Pape opened his foster home in May 2001 with Thomas as one of his first residents. Soon the 26-year-old high school graduate was pulling in as much as $18,000 a month for Thomas and three other women. Over four years, the state sent Pape $725,790.64 in tax-free payments to operate his home.

Pape enjoyed the rewards of his business.

“Every time I had a county official come to my house, they’d say, ‘Wow, Dave, I wish I could afford a truck like this,’” Pape said. “My response to people: Open a foster home.”

Pape said he bought a van, a boat, a car, a vacation time share, a house in Eugene for the residents and another one in Springfield as “a getaway” for him and his wife.

Foster providers have wide leeway over what they do with client service payments. Caseworkers are supposed to monitor whether a client’s needs are being met, but there are no strict accounting requirements.

The county employees who licensed Pape’s home found no problems, annual reviews show. But Lane County officials also admit that case managers visited Thomas at Pape’s home only three times in the two years prior to her death in 2005, despite rules requiring at least 20 such visits.

Records hint that, for Thomas, things were less than ideal.

She took two trips to the emergency room in 2002. In one, she was treated for a large, infected leg wound caused when she set her pants afire with a lighter two or three weeks earlier. In the other, she was treated for weakness and lethargy. At both visits, Thomas told hospital workers she didn’t want to return to Pape’s home.

Notes by Thomas’ case manager say she called repeatedly in 2004 and 2005 to report that she wanted to move. She was lectured for making repeated 9-1-1 calls to complain about her caregivers. Her claims were deemed “false” and ignored, the documents said.

The next time a 9-1-1 call came from Lodenquai Lane, it was Pape reporting Thomas was unconscious in the bathtub. The water had been drained, and the bathroom linoleum had been mopped. Yet the hall carpet was soaked.

Pape initially said he tended to an ill Thomas through the night and saw her get up that morning to shower. “I take good care of my girls,” he told the 9-1-1 operator.

Challenged later by police, Pape admitted he hadn’t been there at all. While he and his wife, the foster home’s manager, celebrated their first year of marriage across town, the home was left in the care of Kane Parks.

Parks, then 20, had recently lost his job at KFC. Pape said he compensated his wife’s younger brother by giving him a free place to live and by “paying for his car insurance.”

Parks told police he called Pape around 2 a.m. to tell him Thomas was “unresponsive” in the tub. In a police interrogation video, Pape said he thought Thomas was just “being manipulative.” He said he told Parks he’d deal with her in the morning.

Still waiting at 9 a.m., Parks served breakfast to the other residents and ordered them to brush their teeth in the bathroom where Thomas’ unclothed body lay. Another hour passed before Pape arrived and called 9-1-1.

After investigating the scene, the county medical examiner and police concluded Thomas had drowned. Authorities charged Pape and Parks with criminal mistreatment. State officials said Pape surrendered his license.

Six months later, however, an autopsy listed the manner of death as natural — from severe, untreated pneumonia. Karrie McIntyre, a former Lane County prosecutor who handled the case, said uncertainty about the exact cause of death lowered the odds of conviction. She called her decision to drop the charges “heartbreaking.”

Soon after, Pape called Lane County and asked for his license back.

Although officials said they would never reissue Pape a license, they said that because he was not convicted of a crime, nothing prohibits him from being hired as a caregiver at another home in Oregon.

Pape says he plans to do exactly that.

In an interview, he said he lied to police and the 9-1-1 operator because he was in “diabetic shock.” Thomas’ death, he said, was the fault of Lane County officials who didn’t “pay me enough for her care.”

Kane Parks could not be reached.

Five months before Thomas’ death, Pape’s home underwent its annual licensing review.

“Wonderful foster home!” the county reviewer had written. “Thank you.”

News researcher Margie Gultry contributed to this report.
Story by Michelle Roberts | 503-294-5041 | | Published November 4, 2007
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