Probes of D.C. Group Home Deaths Are Shifted In-House

By Karlyn Barker
Washington Post Staff Writer
Thursday, August 24, 2006

The District's mental retardation agency has run out of money to pay an independent contractor to investigate deaths in its group home system and is now conducting the probes in-house -- using the same office that previously deleted damaging information from some of the contractor's reports.

Kathy Sawyer, interim head of the Mental Retardation and Developmental Disabilities Administration, said yesterday that the agency stopped referring cases to the outside contractor beginning with deaths that occurred in early June. Sawyer said that when she came on the job in late June, she asked the agency's Incident Management and Investigations Unit to start conducting the probes while she explored other options.

Sawyer, a nationally recognized disability expert who took over the agency under a six-month contract, said the switch was made because funds to pay a private contractor -- an average of $15,000 per report -- were depleted. She stressed that the agency's investigative unit has a new manager and no longer employs those who altered some death reports before the documents were turned over to court officials and others who review cases.

"The people who deleted the records don't work there any more," Sawyer said.

The D.C. inspector general has begun an investigation to determine who altered some of the death reports to remove information about lapses. Deletions in eight of a sampling of 19 reports were discovered this summer by Elizabeth Jones, the court monitor in a long-standing federal lawsuit against the District over care of the mentally retarded.

The decision to stop using the private contractor, if only temporarily, drew immediate criticism. The city has been under pressure to improve conditions and care at the group homes. The death investigations have flagged recurring problems in critical areas such as case management, oversight, nutrition and health care.

Sawyer's predecessor at the agency, Marsha H. Thompson, who was ousted in early June, said she found the independent reports valuable and was unaware that the agency had stopped referring death cases for outside review.

D.C. Council member Adrian M. Fenty (D-Ward 4), chairman of the council's Human Services Committee, which oversees the mental retardation agency, said the timing is particularly unfortunate because a federal judge is currently weighing a request by advocates for those with developmental disabilities to put the agency in court receivership.

"Having an independent organization investigate the deaths was probably the one little bit of credibility [the agency] had left," said Fenty, who is running for mayor in the Sept. 12 Democratic primary.

He called Sawyer "basically just a consultant" and, in a letter he sent to her yesterday, said it would be "a grave mistake" to halt the independent death inquiries.

The private contractor, the Columbus Organization, does death investigations and provides other specialized consulting services for several states. It has prepared death reports for the District for about four years, often relying on expertise of private doctors and nurses.

The Incident Management and Investigations Unit had been part of the Department of Human Services, where it investigated incidents such as injuries and thefts in group homes and reviewed the Columbus reports. The District has said that the records deletions occurred before October, when the unit was put under the control of the mental retardation agency.

Sandy Bernstein, legal director of University Legal Services, which represents plaintiffs in the 30-year-old lawsuit against the District, expressed alarm at the shift to in-house death probes and said her office didn't know about the switch until contacted by a reporter.

The mental retardation agency "does not have the staffing capability or the knowledge to be able to do as thorough an investigation as Columbus does," she said. She said the agency used to do its own death inquiries but fell behind on the reports and hired Columbus to take advantage of its special expertise.

Bernstein said the District should not be involved in investigating itself, particularly given the lack of oversight of the person or people who made deletions in previous death reports.

"Their track record does not leave me with much confidence of getting thorough, timely reports," she said.

Sawyer said she plans to decide by the end of September, after consultation with advocates for the mentally disabled, whether to renew the contract with the Columbus Organization, put the contract out for bid, find another D.C. agency to conduct the investigations or keep using the in-house investigators.

The agency budgeted for about 12 to 15 death investigations this year but has so far referred more than 20 cases to Columbus, Sawyer said, which is why contract funds ran out. She said that the contractor is finishing 22 death reports and that probes of seven more recent deaths are being conducted in-house.

The mental retardation agency has a budget of more than $70 million and serves about 2,000 people with developmental disabilities, most of whom live in group homes across the city.

Sawyer, who once headed Alabama's mental health department, called her job in Washington "a much bigger challenge because I don't have as much to work with."

She said she is getting good support from Mayor Anthony A. Williams (D) and his top staff and expects to make significant improvements at the agency by the time her contract is up at the end of December. But she indicated that she would be willing to stay on under a new mayor.

"I expect to deliver as projected, but if I have any loose ends, I want to make sure I finish my business here, if I'm allowed to," she said.

Sawyer said she is concentrating on basic work to put policies and systems in place. She said she wants to leave the agency with a good investigative unit, make progress in settling the federal lawsuit, improve the case management system and deliver safe, quality care to some of the city's most vulnerable residents.

"I understand the public's frustration and disappointment" with past failings, she said. "My goal is to deliver."

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