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Study shows state failed to report incidents involving individuals with developmental disabilities

Standard-Speaker - 1/24/2020

Jan. 24--A Pennsylvanian with a developmental disability who had to be monitored while eating couldn't resist a plate of pureed grilled cheese.

While a staff member's back was turned, the person slurped down the food, began choking and died.

The provider of care to the person and a regional investigator both concluded the death was a case of neglect.

Yet neither reported to the district attorney, a federal probe found.

The Inspector General for the U.S. Department of Health and Human Services uncovered that incident while scanning records of deaths, hospital visits and allegations of abuse involving Pennsylvanians with disabilities who receive care in community settings between 2015 and 2016.

In a report on Jan. 17, the Inspector General concluded that Pennsylvania did not fully comply with federal Medicaid law and state requirements that say those types of cases must be reported within 24 hours.

Read the report HERE

"We recommend that Pennsylvania improve its controls regarding the reporting and monitoring of ... reportable incidents involving Medicaid beneficiaries with development disabilities residing in community-based settings."

When incidents aren't reported, authorities miss chances to intervene on behalf of people who have been neglected or to take action against providers.

"Because the state agency did not detect that these 24-hour reportable incidents had not been reported, it was not always able to take prompt action to protect beneficiaries' health, safety and rights," the report said.

The report included the following findings:

--18,880 emergency room visits were unreported, and 307 of them were indicative of abuse or neglect.

--167 hospital admissions that went unreported were indicative of neglect or abuse.

--Community-based providers failed to investigate 80 deaths, and regional investigators failed to look into 94 deaths.

In addition, the Inspector General also studied 13 of 654 death reports. Of those 13, the Inspector General found two that hadn't been referred to law enforcement, but they were referred after the federal probe uncovered them.

As a result of the federal inquiry into the death of the person who ate grilled cheese, the state referred that case to law enforcement.

State Rep. Gerald Mullery, D-119, Newport Twp., said the report has bearing on plans to close centers in Polk, Venango County, and White Haven in his district, where more than 300 people with intellectual disabilities live and receive care from state workers.

"Now is not the time to be adding hundreds more to the community-care setting," said Mullery, who has fought to keep centers open.

If the centers closed, the residents could move to either of two other centers that would stay open or to community settings such as group homes or family residences.

Cases covered in the report happened four and five years ago, but since then the department has concurred recommendations made by the Inspector General and improved its oversight.

For example, the department began reviewing claims from emergency rooms and hospitals for diagnostic codes suggestive of neglect such as bed sores or choking. With the University of Pittsburgh, the department is identifying trends in incident reporting that will identify providers who potentially aren't complying.

"The use of claims data to identify unreported incidents is a relatively new practice. The department did not possess the necessary technology or comprehensive understanding of this method in 2015-2016," Erin James, the department's press secretary, said in a statement.

In May 2017, the department started reviewing deaths of all people whose disabilities qualified them for a waiver to receive services in the community.

"Prior to this change, only deaths that occurred in a provider-operated setting were required to be investigated," James said. Most people with waivers "live in family homes, not provider-operated settings, so this is an important change."

In 2018, the department began prompting reviewers to collect and track follow-ups in cases of confirmed neglect or deaths deemed suspicious. James said the department worked with the state Attorney General's office on protocols that have expedited referrals to law enforcement.

On Feb. 2, new regulations will expand the types of incidents that must be reported and give the department more strength to require reports and sanction providers who fail to report.

During the years studied in the report, 18,777 Pennsylvanians with disabilities lived in community settings. Currently, 13,000 people eligible for waivers from Medicaid are on a waiting list to receive services in the community.

Contact the writer:; 570-501-3587


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