INVISIBLE LIVES Milton the cat helps stimulate Eileen, a retarded resident at a home operated by Community of the Ark, acknowledged as one of the District’s best. (Michael Williamson – The Washington Post) • Photo Gallery D.C.'s Troubled System For the Retarded Sunday: • Forest Haven Is Gone, But the Agony Remains • Olympic Achievements Out of Reach • An Elaborate Structure of Care • Hundreds of Abuses, No Fines Monday: • Residents Languish; Profiteers Flourish • Nonprofits Struggle in Current of Greed • Death Among the Mentally Retarded

Second of two articles

By Katherine Boo
Washington Post Staff Writer
Monday, March 15, 1999; Page A1

Frederick Brandenberg carried a Bible and lisped through ill-fitting false teeth. He loved country ballads and, unfortunately, sang them -- his voice could knock starlings from the sky. His life at a Wisconsin Avenue NW group home passed about as normally as life passes for a retarded person in the care of the D.C. government. Until one winter morning.

"Alert, smiling," noted his doctor in the last week of Brandenberg's life, declaring the 57-year-old free of a cold. "Active and talkative," reported a health inspector who happened, the same week, to be doing an annual inspection at the home -- one of 14 facilities for the mentally retarded run by a for-profit company called D.C. Family Services. But the inspector was jarred on the second day of her visit. Brandenberg was in the throes of what she termed "a major change": lethargy so pronounced that she suspected he'd been drugged. The guy with opinions on everything -- why University of Virginia football mattered, why old black-and-white movies are better than candy-colored new ones -- could this January 1997 morning barely rise from his bed.

When the inspector inquired, a group home staff member said that Brandenberg had been sedated with Ativan, a potent tranquilizer, to calm him down for a morning appointment at George Washington University Hospital -- an appointment, the staff member said, the clinic had suddenly canceled. Health inspectors later learned that the group home itself had canceled the appointment. Brandenberg remained so heavily sedated at dinner time that it took two staff members to hold him up to sip a Coke.

The next day, still lethargic, Brandenberg started sweating, breathing slowly, according to a subsequent D.C. Health Department report obtained by The Post. No one called a doctor. No one recorded his vital signs. And the following morning -- 48 hours after being drugged, and without recovering from the sedation -- Fred Brandenberg was dead in his bed.

A decade ago, when retarded people died in the District's asylum called Forest Haven, in Laurel, they were removed to shallow graves in an unmarked field, from which the overflow of a nearby creek would sometimes disinter them. But in 1991, with the aid of a federal lawsuit and the U.S. Department of Justice, Brandenberg and his peers were rescued from the place that had become national shorthand for the inhumanity of large institutions for the mentally disabled. They were requited for their suffering by what was designed to be one of America's most compassionate social policy reforms. Forest Haven shuttered, they were brought home to the District and the presumptive safety of their community's watchful eye.

Today, the District's mentally retarded population is among the most deinstitutionalized in the country. More than 1,000 people under city care are scattered among 150 homelike facilities run by private contractors in neighborhoods from Chevy Chase to Congress Heights. The services the retarded receive -- in their group homes, and in therapy, skills training or work programs they attend daily outside the home -- cost as much, per person, per year, as four years at Harvard.

A decade into reform, however, a Washington Post investigation has found that the ideal of compassionate care and municipal accountability has yielded to a reality of profiteering and fraud, facilitated by city agencies that have for years demanded little accountability and little human decency in return for a vast outlay of public money. For corporate wrongdoers, the consequences for cruelty and neglect have been negligible. For the city's retarded men and women -- men and women who are politically, and sometimes literally, voiceless -- the consequences have been swift, direct and sometimes fatal.

A review of tens of thousands of documents from four city agencies and the federal courts revealed more than 350 incidents of abuse, neglect and robbery of retarded residents in the '90s. A sampling: A man tied up after "making noises" and "asking for cookies." Clients so drugged by their caretakers they kept falling down. A woman starving because her for-profit group home wouldn't buy her what a doctor and a nutritionist were begging for -- a few cans a day of a liquid supplement called Ensure. Yet none of these and other documented reports of abuse led to fines or criminal penalties against the offending group home operators.

The group home and day program operators treated with such lenience included a convicted embezzler and a D.C. nightclub owner on his way to prison. A high-level city official responsible for monitoring the quality of day programs bought a private home for a contractor he was overseeing -- a popular treatment provider who, court records allege, billed Medicaid for thousands of treatments she didn't actually deliver to the retarded in her care.

And then there are the dead. Fifty-three group home residents have died in the last three years. When retarded people died at Forest Haven during its final years, the Justice Department rushed in to investigate whether poor treatment had contributed. But of the 53 recent deaths, only three have received even cursory inquiry from the city or federal government.

Frances Bowie, administrator of the Department of Human Services agency that serves as custodian of the District's retarded wards, says the deaths are a demographic inevitability: The average group home resident is over 40, with "a lot of medical problems." But her agency refused to release the names or ages of the dead, or even summary information about how and where they died, citing privacy concerns. The Washington Post identified Brandenberg only after dozens of inquiries within the community where he died.

Operating without public scrutiny, city officials have routinely closed death cases with no more than a brief account written by an employee of the group home or day program -- the entities that might be liable if poor treatment were found to have contributed. A paid representative of D.C. Family Services Inc. probably would have written the story of the death of Fred Brandenberg, too, except for happenstance: A health inspector had witnessed the prolonged sedation that preceded his death.

The Health Department's conclusions about Brandenberg's death were dark. It found that the group home staff had not only lied about one missed medical appointment, but also had withheld previous key medical treatment. Although Brandenberg had a history of heart disease, the home had failed to carry out orders by his cardiologist to increase his heart medicine and to obtain lab tests to ensure that the treatment was working.

The report didn't note a fact contained in health inspectors' own files and in the files of D.C. Medicaid monitors assigned to safeguard the federal funds spent for care of the city's sickest retarded people: In the previous two years, poor medical care had been found repeatedly in homes that D.C. Family Services runs across the city. Just three weeks before Brandenberg's death, for instance, health inspectors cited a D.C. Family Services home for delaying medical treatment to a profoundly retarded man who had received two head injuries over the course of a few days -- and who had been physically restrained by what health inspectors called "hostile staff."

Sheila Gaither, co-owner of the company, declined to comment on Brandenberg's case. Her partner, Capitol Hill dentist Arthur Stubbs, did not return repeated phone calls.

Last year, D.C. Family Services received $6.3 million in public funds to run its group homes, records say. And last November -- about the time that health inspectors cited another case of medical neglect at Brandenberg's old home -- the Department of Human Services awarded $6.6 million to another company run by Gaither and Stubbs, this one to help welfare recipients get jobs.

Fred Brandenberg didn't even get the autopsy that, records say, his doctor requested from the city. The D.C. medical examiner didn't perform one. "If we had known the full circumstances, there probably would have been an autopsy," said Jacqueline Lee, the deputy chief medical examiner.

Health inspectors didn't refer their findings to the U.S. attorney or anyone else; they say they haven't referred a group home death to higher authorities in five years. The death certificate read: heart disease. The case was filed away. After a life of not quite being there, Fred Brandenberg was gone altogether. And the Department of Human Services assigned another retarded person to his bed.

City officials, responding to The Post's findings, acknowledged systemic failures that have hurt the well-being of the retarded after the closing of Forest Haven: poor monitoring they attributed in part to budget cuts, miscommunication among agencies and a failure to implement regulations that would allow companies that mistreat the retarded to be fined.

On documents turned over to The Washington Post under the Freedom of Information Act, city officials -- citing the privacy of the retarded -- expunged the name of Fred Brandenberg and thousands of his peers with heavy swaths of black ink. The symbolism sears. This is a story of lives and deaths that, even in the midst of communities, remain invisible.

Swollen Into a Moon

Peterson came to Washington in the early '90s with a PhD in physics, a dissertation on a technical aspect of quantum chemistry called "valence bond calculation" and a wandering entrepreneurial eye. It fell on the former residents of Forest Haven.

Peterson already ran a few group homes for the retarded in Ohio. And as Forest Haven closed, the District was paying some of the country's highest rates for caring for the retarded, as much as $500 a day. Care for the city's 700 or so medically needy retarded brought in the most money: federal Medicaid funds for day treatment and residential care. The 400 healthy retarded received lower-cost, city-financed housing and treatment. Peterson chose the sick, adding a string of D.C. homes to his holdings.

He entered the District's system at a time when the role of for-profit operators was exploding. From 1985 to 1998, the number of private group homes in the District grew from a few dozen to about 150 -- 80 percent of them run by for-profit companies. Some of those companies ran only a home or two; some ran more than a dozen. Peterson soon had four.

The rates that providers like Peterson receive are set by negotiation with the local Medicaid office and are theoretically based on the cost of client care. Shortly after Peterson opened his D.C. homes, Medicaid memos indicate, he requested and obtained additional money to address his clients' expensive needs. It was a tactic he had used in Ohio, whose attorney general later found that one reason his costs were high was that he was skimming off hundreds of thousands of dollars for his personal use.

By 1997, Peterson's company, Brice-Warren, was receiving $2.5 million a year in federal funds to care for 24 D.C. clients. Meanwhile, city records show, money was disappearing regularly from his clients' private accounts -- usually tiny Social Security checks that Peterson and his staff were entrusted to manage. Medicaid officials would make Peterson's company put the money back. Then the money would disappear again. (A 1998 Department of Human Services audit of client accounts in group homes across the city noted that deductions had frequently been made from such accounts without the requisite documentation.) Meanwhile, in another corner of the city bureaucracy, health inspectors charged with surveying the homes and investigating complaints were compiling report after report of abuse and neglect in the Brice-Warren homes.

In the summer of 1996, a resident of a Peterson home on 11th Street NW arrived at her day treatment program aching, her face swollen into a moon. Beneath her clothes, 36-year-old Irene was a map of contusions. The day program staff members called the health inspectors, who went to 11th Street to look more closely at the lives of the six men and women who lived there. What they found was startling. In the same week as Irene's beating, according to their subsequent report, a neighbor reported seeing a staff member hit a woman after she declined to take a bath. Another staff member was seen chasing a retarded man down the street, threatening him with a stick and warning him of punishment with a belt. Sticks and belts weren't the only implements of discipline in the house, an employee later told investigators: One staff member preferred to give clients a blast in the face from a "chemical spray."

A week after Irene's injuries, another resident began to suffer seizures. City records say that the staff didn't dial 911 until eight hours after the first convulsion.

Health inspection records note that a year before Irene was hurt, a different neighbor of the home called the Department of Human Services to complain that clients were being abused. The agency can locate no record of an investigation. But even when agencies do earnestly investigate abuse allegations in group homes, they often don't get very far, records show. Homes often attribute wounds -- the cigarette burns on one man's back, the bruises on many arms, legs and pelvises -- to accident or self-mutilation. Sometimes those explanations may be truthful. And when they aren't, the clients competent enough to explain what actually happened may decline to criticize the group home staff that may be the closest thing to family they have.

Nor could the inhabitants of Peterson's homes count on the court-appointed personal advocate the District's generous protection laws mandate: a trained volunteer, assigned to each retarded ward, who visits the client's home and day program and fights to get what he or she needs. The program to recruit and train such volunteers, which is run out of D.C. Superior Court, has foundered: There are currently 148 certified advocates for nearly 1,000 wards.

The retarded did have, when Irene was hurt, diligent health inspectors on their side. Those inspectors eventually documented that four of 11th Street's six residents had been beaten or otherwise abused by their caretakers, who had also failed to report many serious incidents and injuries in the home. But all the inspectors could do was ask Peterson for "corrective action," as they routinely ask providers when they find problems. Only when providers fail repeatedly to undertake corrections can the city revoke Medicaid funding, something that hasn't happened to a group home for the retarded in years. Nor could inspectors slap a fine on Peterson's company, like the $100,000 penalties that can be levied on nursing homes that neglect their patients. That's because the District -- whose laws permit strong monetary sanctions on facilities that maltreat the retarded -- has never promulgated a schedule of fines that would allow the penalties on the books to be imposed.

Because Peterson's funding came from the federal Medicaid program, the District's Medicaid office also was charged with monitoring his finances and program quality. But it had only two fraud detectors to monitor a budget that is bigger than that of the D.C. public schools -- $840 million today. As for the Department of Human Services, many of the caseworkers assigned to protect the well-being of group home residents were haphazardly retrained Forest Haven staff members, who were further demoralized by mass department layoffs.

There was no broad inquiry into Peterson's operations in the wake of the findings of abuse at the 11th Street group home. In fact, the Medicaid office, which is supposed to audit company billings annually, hadn't audited Brice-Warren once since it started its D.C. operations in 1991.

If there had been an inquiry, it might have discovered that, months before Irene's injuries, Peterson had been indicted in federal court in Ohio for stealing $430,000 in federal money intended for that state's mentally retarded -- and spending those stolen funds on jewelry, go-go dancers listed as "group-home consultants" and an elaborate sound system for a Columbus strip club called Dancers and Dreamers. In May 1997, Peterson was found guilty in Ohio and sentenced to prison.

By the time Medicaid officials finally tried to examine seven years of multimillion-dollar payments made to his D.C. homes, his company had been dissolved; his books had vanished. Peterson, contacted in federal prison, declined to comment.

Marcus Veazey, supervisor of a new unit of the FBI called the D.C. Health Care Fraud Squad, says the District is a particularly difficult place to catch Medicaid corruption: "There haven't been a lot of audits of providers because the city regulators are understaffed. So you end up with providers who know they're not being looked at. Those who want to get involved in criminal activity will because they don't think they'll get caught."

Today, a new for-profit corporation, RCM, runs the former Peterson homes. But inspection reports from the facilities ring familiar. In 1998, records note a client molested by another resident who remained in the home; a patient burned as a result of staff negligence; clients given psychotropic medication without the requisite psychiatric approval; and money missing from client accounts. RCM's director, Marsha Brevard, says the company has recently poured funds into physical improvements and quality control -- efforts that have thus far staved off city attempts to penalize the homes for poor quality.

Brevard notes that Carl Peterson calls collect from time to time, from prison. The owners of the new company are Amy Brooks, Peterson's longtime deputy, and Brevard, his old partner in, among other businesses, the now-bankrupt 360 Club.

Friendly Oversight

Every retarded person under the mental retardation administration's aegis receives an annual assessment of what he needs to maximize his physical and mental well-being: a road map to his care. Enter Smith One: psychologist Denise Braxtonbrown-Smith, with whom the city contracted after Forest Haven's closing to help do these annual assessments. Like many of those who served the retarded after Forest Haven closed, she was an entrepreneur as well as a psychologist. Besides doing assessments, she ran her own treatment companies -- which sometimes provided the very therapies she recommended for the clients she was assessing. One of those companies, Better Treatment Center, was soon charging $175 a day per client served, by far the highest rate for day treatment in the city.

Last October, the D.C. corporation counsel charged in a civil action that from 1995 to 1998, Braxtonbrown-Smith's companies filed $10 million in false and inflated claims for services. Taxpayer funds paid for the alleged psychoanalysis of 70 retarded people, even though the profoundly retarded are implausible candidates for analysis, and even though there are few records to indicate that clients actually saw a psychotherapist. Taxpayers also financed services rendered to clients who were hospitalized or dead, according to the District's court pleadings. In January, Smith's chief financial officer, Kenneth Strachan, pleaded guilty to criminal conspiracy in a case stemming from the false-claims scheme. He said in court papers that he helped Smith bilk Medicaid and pocket the profits.

Braxtonbrown-Smith declined repeated requests for comment. No charges have been filed against her.

The city official charged with safeguarding the retarded in such programs was, during most of the '90s, Smith Two: Arnett Smith, the mental retardation administration's chief of day programming and no relation to the psychologist. No family relation, anyway. In 1994, real estate records show, Arnett (who was married and lived elsewhere) bought a home on Columbia Road NW for the use of Denise.

Arnett Smith says of Braxtonbrown-Smith, "I treated her like everyone else." He declined through his lawyer to answer questions about his purchase of the home where Braxtonbrown-Smith lived, which he later sold.

Arnett Smith also had a business on the side: He sold travel packages to group homes for the mentally retarded, hiring other employees of his agency as his private company's staff. The nonprofit St. John's Community Services was one of several providers that complained to Smith's superiors that they felt pressured to buy these travel packages or lose their clients and contracts. Nevertheless, Smith ran his business with city permission until he retired in 1996 -- after which he went to work as a paid consultant to Braxtonbrown-Smith.

Today, he receives city funding to run a Southeast group home for the mentally ill.

A 42-year-old named Charlie Johnson was one of the retarded clients reliant on the two Smiths' care. At long tables at a 13th Street NW storefront, he and other retarded people spent several hours a day folding washcloths -- labor for which Braxtonbrown-Smith earned income through contracts she negotiated with private companies. By law, people like Johnson may be paid less than the minimum wage if their work is part of a treatment or job training plan. Last fall, after the city sent Johnson to one of its better group homes, the Community of the Ark, a staff member thought to check his pay stub to see exactly how much less than the minimum wage he was getting for his labor.

Over one two-week pay period, Johnson earned 85 cents.

As Braxtonbrown-Smith's programs grew large with city money, some respected, low-cost programs for the retarded lost their clients and contracts. For instance, by the mid-'90s, Rehabilitation Opportunities Inc., a nonprofit sheltered workshop, wasn't even getting clients the city had already paid for. "For the last years, we hardly ever saw a monitor or a caseworker," said Executive Director Rory Brett, whose group now serves only Maryland clients. "There was no benefit to running a good program and no penalty for running a bad one." Arnett Smith did visit occasionally, Brett recalls -- not to check on the retarded, but to drop off brochures about his travel agency.

And even when city officials do trip over a bad program, they may be forgiving. The mental retardation administration continued to pay Braxtonbrown-Smith to care for Johnson and other retarded people for six months after being notified that the District's own lawyers were suing the psychologist for fraud.

'Work Cut Out for All'

City officials also told The Post they will finally promulgate the necessary fine schedules so that the city can punish abuse and neglect of the retarded.

"We've got our work cut out for all of us," says Department of Human Services Director Jearline F. Williams.

One of the first jobs will be getting agencies to trade information -- to begin identifying patterns of abuse or corruption that now get missed. The need for that broader view is illustrated by the recent history of the District's largest nonprofit group home provider: a company called D.C. Community Services. In the '90s, its managers have included a convicted embezzler and six others found guilty in Massachusetts of diverting money meant for the retarded to personal use.

Embezzling officers were not the nonprofit's only recurring problem. Consider the experience of a mute, severely retarded woman named Angela, who in 1997 was sent by the city to one of D.C. Community Services' 12 group homes. There was a vacancy at this Northwest Washington home because a previous resident had fallen out of the home's van and, caught in the door, been dragged face down on the pavement. A month after moving in, Angela, too, came to harm in the van. According to health inspectors' documents, a staff member pounded her head and upper body because she unfastened her seat belt. A woman driving behind the van, herself the mother of a disabled child, bravely intervened. Health inspectors substantiated her account of the beating. But bloodied Angela remained at the home.

Videotape shot at her day program two months after the incident shows her slumped and oblivious, day after day. In March, health inspectors cited D.C. Community Services for improperly drugging her -- a citation that came, as always, with no fine.

Meanwhile, the Mental Retardation and Developmental Disabilities Administration, Angela's official caretaker, was seemingly unaware of her suffering: Records it provided to The Post show that trained monitors visited her home once between 1994 and 1998. Angela's caseworker did drop in after her beating and the drugging, records show. Noting no unusual incidents involving his client, the caseworker pronounced her living situation "good."

Running D.C. Community Services at the time of Angela's injuries was a man named Steven Pullman, who had been named to the job after the previous executive director had been convicted of defrauding the government and the nonprofit's board of directors. But Pullman himself had been convicted in the late '80s of bilking the Town of Vienna in his role as its chief financial officer. He stole the money, he told the judge, to finance a $500-a-day cocaine habit. Pullman, who declined to be interviewed, resigned from D.C. Community Services last summer -- shortly after its board of directors learned that the company no longer owned many of the homes where its clients live. A civil lawsuit filed by the board alleges that, through a series of unauthorized maneuvers, Pullman converted many of the nonprofit's homes, vans and other assets to his own name. Pullman says in a counter-suit that the deals were approved by the board president, the director of a Capitol Hill nursing home, and were appropriate.

As those charges of impropriety played out in court last year, D.C. Community Services collected about $5 million in city and federal money.

This year, D.C. Community Services has a new executive director, Nathaniel Jenkins, who has run programs for the retarded in Maryland. He said, "I have observed personally that the care going on is excellent." He declined to comment about Angela, whose home -- one of the few D.C. Community Services still owns -- appeared earlier this month in a tiny notice in the Washington Times. It was scheduled for auction because the nonprofit hadn't made its mortgage payments.

A World Without Words

But outside the claustral realm of the retarded, his death didn't resonate much. Perhaps that was evitable: The opinionated, off-key 57-year-old retarded man wasn't a fully functioning member of society, or even one of the docile disabled who sweep up stray french fries at McDonald's. But from a certain angle, there is particular tragedy in being born with very little and losing some or all of that.

In being 22-year-old, retarded, paraplegic Robert, who has legs the length of rulers, feet short some toes, chronically sopping Huggies -- and a mind uncannily able to recall every song in the hymnal.

Given up by his birth mother, then a foster one, he now has been sent by the city to his first group home. And he, who grew up without the shaping scars of Forest Haven, whose smile says, Stay and talk: He represents whatever hope there is.

"Where do you live?" Robert asks a rare visitor, fingering his bib. "Do you love me?" He allows that he has learned his address and his ABCs. But his attempts at dinner-table conversation are interrupted. His profoundly retarded housemates have forsaken their chicken noodle soup to hurl themselves against the living room walls.

There are benevolent laws on the books. There is money in the budget. There is magic in this lonely, miniature man. But District officials have placed him in a world without words.

One of his housemates bangs his head mutely. Another howls and pounds in need or anger. Two aides silently intervene. And Robert freezes, orange jello trembling on his spoon.

O beautiful, for spacious skies
For amber waves of grain. . . .

Urgently, exquisitely, Robert tries to do what his city hasn't done for him. He comforts himself. He sings, until the heads hitting drywall overwhelm.