Three people dependent upon state health regulators for their safety have died of apparent neglect in the past two years at Midlands assisted-living homes.
One death, at a Columbia residential care center, went beyond neglect, said Richland County Coroner Gary Watts.
He said a medically unqualified staffer gave a 50-year-old man an insulin overdose that killed him.
Watts is investigating the death as a homicide.
His concern doesn’t stop there. He and others are increasingly alarmed about deteriorating conditions in the homes and whether there are enough state inspectors to ensure residents’ safety.
Watts blames lax state laws and a patchwork system of poorly communicating state agencies. Other agencies are involved, he said, but at the problem’s core is the state Department of Health and Environmental Control.
DHEC is responsible for licensing and overseeing the homes, designated for those who are mentally and physically disabled, but not seriously enough to be in a nursing home. DHEC also inspects conditions in the homes.
“How do you allow someone who’s unqualified to dispense medication?” Watts said of what he called DHEC’s faulty oversight.
Joining Watts in his alarm are law enforcement and caregiver agencies across the state.
Mental health advocates and the state Sheriff’s Association say lives are at stake and something needs to be done — now.
“Community residential care facilities” is the legal term for the little-known network of homes serving some of the state’s weakest and most vulnerable people.
Nearly all need help — being reminded to take medicines, for example — to make it through the day. They have a variety of infirmities: Alzheimer’s, mental incapacities, HIV-AIDS, kidney diseases that require dialysis, mobility issues that put them in wheelchairs. Many are elderly and frail.
Complaints are up so much at the homes that DHEC in late October hosted a meeting with home operators, state agency representatives and advocates for the disabled to discuss problems. The public and press were not notified of the meeting, and a reporter who tried to attend was barred. DHEC commissioner Earl Hunter said through a spokesperson that a press presence would have a “chilling effect” on participants.
But a confidential DHEC memo obtained by The State announces the meeting by saying: “Recent events involving unacceptable care situations ... and a significant increase in resident and family member complaints indicate a need for (DHEC) to reassess the present regulatory approach.”
The Sept. 26 memo says home operators are “often unable to achieve the level of care necessary” to comply with state laws.
LACK OF MANPOWER
But while DHEC points a finger at the operators, critics say the agency bears much of the blame.
DHEC lacks the staff to properly oversee the 16,000 or so residents in the 488, mostly privately owned, homes, they say.
DHEC does not have enough inspectors, said Jeff Moore, executive director of the S.C. Sheriffs’ Association. “As a result, they can’t respond in a timely manner to the complaints they get.” Sheriffs across the state answer calls about disturbances and mentally ill people wandering away from the facilities, Moore said.
DHEC’s Dennis Gibbs, who helps oversee health licensing, said indeed, the agency at times has not had enough inspectors for the nearly 500 homes.
He said DHEC now has 13 positions for people who inspect the homes as well as the 80 or so additional homes for the mentally retarded. DHEC spokesman Thom Berry said none of the 13 inspection positions are devoted exclusively to inspections of residential care homes.
DHEC easily could use 26 inspectors, “if money were no object,” Gibbs said.
Gibbs said there are enough inspectors to handle serious complaints promptly, but the agency has to prioritize less-serious complaints.
Mark Binkley, attorney for the state Department of Mental Health, attended DHEC’s closed-door meeting.
“DHEC obviously has difficulty in getting the manpower to get around to all the residential health care facilities on a regular basis,” Binkley said. DHEC’s lack of manpower “was a major topic of conversation,” he said.
But inspections aren’t the only problem, according to a former longtime employee who once headed the agency’s health licensing program. He said DHEC has a common practice of not being tough on businesses it regulates.
“DHEC often tries to work with a violator, and then the next thing you know, all hell breaks loose,” said Jerry Paul, a former upper-level DHEC health licensing official who retired last year. Trying to work things out gets compliance in some cases but only encourages hard-core violators, he said.
Paul said DHEC staffers are forbidden to mention to the media its practice of not being tough on violators. He said he feels free to talk now because he has left DHEC and doesn’t believe in being soft on violators when lives are at stake.
“Our job is to protect the residents. We are not there to protect the business owners. If we lose sight of that, we might as well junk the whole program,” he said.
Hunter declined to respond to Paul’s comments. He said DHEC has “a responsibility to go in and make sure these homes are properly licensed to the standards that are established by the General Assembly. We can only do so much.”
For the past two years, DHEC has asked the General Assembly for money for two more inspectors. Each request was turned down, Hunter said.
AGENCY DOESN’T TRACK DEATHS
DHEC can’t say how many people are injured or die each year in the homes, from natural or other causes.
The agency produces annual reports for some of its divisions, such as its garbage landfill division. Those are usually required by law and supported by grant money, officials said.
There’s no money or legal requirement to compile reports on the state’s residential health care facilities, officials said. DHEC in recent years has not asked the Legislature for money for such a report, according to budget documents.
Some homes are of a high quality, such as the Still Hopes Episcopal Retirement Community in West Columbia. Others — including the unsafe and now-closed Peachtree Manor in Fairfield County — are low-quality homes of last resort, the only care some residents can afford.
State agencies use many of the homes as an informal place to put poor people who have disabilities.
It’s standard practice for hospitals and the Department of Mental Health to refer former patients there. The pace, and number of patients, increased as South Carolina, like other states, began closing its mental hospitals.
“It is an unofficial housing system, and it’s a pretty poor way to do it,” said Bill Lindsey, executive director of the National Alliance on Mental Illness in South Carolina, an advocacy group. “Some facilities do a good job, but others are horrible.”
In the Richland County fatality, Watts shared pertinent parts of the 2007 death certificate but declined to identify the victim, the alleged suspect or the facility while the probe continues.
In another of the three recent cases, a Newberry County grand jury Oct. 24 indicted the operator of a Prosperity care center for felony neglect of a vulnerable adult resulting in an April death. The third death happened in 2006 at Peachtree Manor when a resident in a wheelchair left the facility without supervision and was struck and killed by a car. No charges were filed.
NOT NURSING HOMES
“Residential care facilities” are not nursing homes.
South Carolina has more than twice as many residential care facilities as it does nursing homes. In addition to DHEC, the federal government regulates nursing homes that accept Medicare or Medicaid and imposes high standards on them.
Only less-rigorous state laws cover residential care facilities. Typically, the 488 facilities have far fewer staff than do the state’s 191 nursing homes and aren’t required to have on-site nurses.
The care homes vary from about five to more than 100 beds. While most are privately run, for profit, some are run by churches or other groups. Some are mom-and-pop operations. And they fill a niche.
“Many of our hospitals don’t provide psychiatric services,” said Jim Head, senior vice president of the S.C. Hospital Association. “So you have an E.R. doc with a patient who needs placement somewhere.”
Head said his group doesn’t keep track of the number of patients referred to the homes.
But the state Department of Mental Health placed 1,390 of the homes’ approximately 16,000 current clients. Many were just released from state mental hospitals, officials said.
Often times, only the low-cost homes are available for the poor who are mentally ill or disabled.
And many low-cost homes are in business to make money. They accept for payment monthly government subsistence checks received by their residents.
Their operators can struggle to meet minimal legal health and safety standards, officials say.
Watts said DHEC needs to ensure quality care at all facilities.
He said it’s not fair for poor people to get such bad care in many homes, while the well-to-do get top care. “We are letting down the poor people of this state when we treat them like that.”
Nikki Robertson, president of the S.C. Association of Residential Care Homes, declined to be interviewed about care conditions.
Her group represents 182 facilities with 6,900 beds, or about 37 percent of the homes. She referred to DHEC questions about whether DHEC has enough inspectors.
CHECKING BEHIND DHEC
State mental health advocates will go on the record. They say DHEC is struggling to adequately oversee the homes.
The Department of Mental Health is concerned enough to do its own random inspections of many of the 488 care facilities, contracting with the Columbia-based Protection and Advocacy for People with Disabilities Inc.
Last year, of random unannounced visits to 85 facilities, the independent advocacy group found conditions at 36 that it thought warranted a complaint to DHEC. DHEC later cited 42 of the 85 facilities for violations.
“Some (complaints) bordered on life-threatening things,” said the group’s Gloria Prevost. “Others are more quality of life. If you’re living there, they are pretty horrible, but they wouldn’t rise to life-threatening.”
But the advocacy group has decided to do more.
Prevost said it is finalizing a study on conditions in residential care facilities. Prevost said the study examined, among other things, staffing, oversight and whether it’s too difficult to close a substandard facility.
Closure processes are fraught with delays, especially if an operator hires a lawyer who appeals a DHEC closure order to the state’s Administrative Law Court. The court can take months to decide a case — allowing even the worst of facilities to stay open and continue to accept residents. It took more than a year, for example, to close Peachtree Manor despite multiple serious complaints.
“The system was set up with a lot of due process for the administrator and not so much for the residents who live there,” Prevost said. “It’s dysfunctional.”
DHEC agrees the appeals process is lengthy. Changing that would take an act of the Legislature, DHEC officials say.
Another agency with some oversight of the facilities is the State Ombudsman’s office, which fields complaints from the homes.
Last year, the office handled 2,560 complaints, said state ombudsman Dale Watson. The top three involved alleged misadministration of medicine, physical abuse and verbal abuse, she said.
The ombudsman’s office’s job is to “make life better for the resident right then” by trying to work things out with the home, Watson said. Her office passes verified complaints to DHEC. Watson’s spokesman declined specific comment on whether the office is satisfied with DHEC’s handling of the complaints.
Another agency with oversight is the State Law Enforcement Division. It formed a vulnerable victim’s unit last year to address escalating reports of children and dependent adults in harm’s way.
Unlike SLED, Mental Health and the state ombudsman, the state Department of Health and Human Services performs no oversight. But it has a lot of taxpayer money on the line.
HHS manages a supplemental aid program for Social Security disability recipients who can’t take care of their basic needs. The money, about $16 million, supports about 4,800 residents.
HHS does not want to give money to people to live where they could be victims of neglect, said spokesman Jeff Stensland. But HHS does not have inspectors to go into the homes and ensure all is well, Stensland said.
So HHS has to take DHEC’s word for how well the homes are operated.
“We absolutely depend on DHEC,” he said.
Reach Monk at (803) 771-8344. Reach Fretwell at (803) 771-8537.