A Nov. 29 article about deaths in the District's group homes for the mentally retarded misstated the number of plaintiffs in a federal lawsuit against the city. There are 700 plaintiffs in the suit, all former residents of Forest Haven, a now-defunct institution for the mentally retarded. About 1,300 other people with special needs also receive services from the city's Mental Retardation and Developmental Disabilities Administration. They are not plaintiffs in the suit. (Published 11/30/2005)

The District government is failing to provide adequate care for mentally and physically disabled residents in its group homes, according to a court monitor who found that a pattern of neglect led to four deaths in the past year.

One woman and three men "are dead because they did not receive timely and competent health care," court monitor Elizabeth Jones said in a newly released report.

Jones expressed "grievous concerns" about the health and safety of hundreds of disabled people who live in the group homes, especially those with special health risks. The deaths, she warned, "reflect the lack of meaningful safeguards in the system."

The report did not identify the people who died or their caretakers. Jones attributed the deaths to serious neglect by two contractors that operate some of the homes and to shoddy oversight by the city, particularly case managers assigned to track the care of individual residents. Two of the people who died were in the same home.

The city, Jones said, has failed to penalize poorly run group homes.

The findings reflect long-standing concerns about the District's care of some of its most vulnerable residents. Mayor Anthony A. Williams (D) vowed to make reforms several years ago amid complaints about abuse and neglect.

The four deaths might have been prevented if the city's Mental Retardation and Developmental Disabilities Administration had followed up on recommendations for improving care in the homes -- and if the agency's case managers had been more vigilant in addressing critical problems, wrote Jones, whose staff reviewed medical records and death investigations.

The agency did not respond to a request seeking comment on the report.

The monitor reviewed the care of people deemed to be at risk. She found that health-risk management plans were out of date in 63 percent of the cases. In 61 percent of the case notes reviewed, residents had not received eight visits a year by their case managers, as the city requires.

The deaths Jones cited in her report occurred between November 2004 and September. She described numerous problems, including the failure to monitor diet and nutritional care; poor communication between group home operators and hospitals; delays in treatment because a person who died did not have a legally appointed guardian; and the failure of the mental retardation agency and the group home operator to check the qualifications of the staff at the home.

One of the deceased, Jones said, had been identified as having a high health risk. "Nevertheless, there was an extraordinary lack of vigilance about his care and treatment," she said. And although the home where he lived has since been closed, "there have been no sanctions against this provider, nor were there actions taken to ensure that the staff involved did not continue to work with other individuals at risk."

The report was filed Nov. 3 as part of Jones's quarterly review in a nearly 30-year-old lawsuit against the District that centers on the quality of care for the mentally retarded, many of whom also have severe physical disabilities.

At a status hearing in the case yesterday, U.S. District Judge Ellen Segal Huvelle expressed concern about the deaths and the slow pace of District reforms. The city, she said, "is being judged on two very important things: Are people getting the services, and are people dying?"

Maria Amato, a lawyer with the D.C. attorney general's office, said that the circumstances surrounding the deaths were complicated and that she was not sure "the finger can be pointed" only at the mental retardation agency.

She and Marsha Thompson, who became interim administrator of the agency in April, said the city has taken several steps to improve services and training and to safeguard group home residents. The city, they said, now has an interagency coordinator and is implementing a 90-day plan, which began Nov. 7, to move 38 at-risk residents into better homes.

Addressing the problem of lax case management, Thompson said the agency, part of the Department of Human Services, "has a long history of nonaccountability." She said she plans to increase the number of mandatory visits to 12 a year and is requiring case managers to provide a daily work schedule.

The agency has about 80 case managers with caseloads that range from 15 to 30 clients, depending on the intensity of their needs.

Sandy Bernstein, legal director for University Legal Services, which represents the plaintiffs in the suit against the District, criticized what she called "short-term approaches" to dealing with such serious failings by the city.

"The situation for [plaintiffs] is grim," she told Huvelle at the hearing. The timetable for addressing problems is so slow, "it will take seven years to get through" the entire group of plaintiffs, she said.

"We've had preventable deaths before," Bernstein said in an interview. "But I don't think it's ever been this clear how dangerous it can be when the system does not work."

The suit covers about 700 plaintiffs, all former residents of Forest Haven, a now-defunct institution for the mentally retarded. Another 1,300 plaintiffs are special-needs clients of the agency.

In 1999, a series of articles in The Washington Post disclosed 350 documented cases of abuse and neglect, as well as profiteering, in the city's group homes.

The series found that none of the 116 deaths that had occurred in the homes since 1993 had been investigated.

District officials said they have since overhauled the mental retardation agency's services, including investigating deaths in group homes and recommending changes to address deficiencies that might have contributed to the deaths.

In January, however, Huvelle expressed frustration with the pace of reforms and ordered Williams to assign a deputy mayor to take charge of the District's long-promised improvements. In April, the head of mental retardation services and two top aides were replaced in what officials said was a departmental restructuring aimed at speeding efforts to change.

The Post has requested copies of group-home death investigations conducted in recent years with the identities of the deceased deleted. The Department of Human Services has rejected the request, citing confidentiality concerns.