Important Negative Findings of the Independent Reviewer, Revealing Community Dangers for Those Moved from Training Centers

From His Third Report, Dated December 6, 2013* The Commonwealth is not in compliance with many cited requirements of the settlement agreement, noted throughout the report. The transition raised significant challenges. These included stress for case managers and their supervisors and concerns with rigid timelines and the unintended consequences. Pg. 20 6 individuals had major events yet only half that number received modifications to their Individual Service Plans as a result. Pg. 21 The Commonwealth is not in compliance with the requirement for CSB emergency personnel crisis response training, nor with the requirements that START crisis personnel work with law enforcement to prevent negative encounters. Pg. 31 Crisis stabilization programs are not fully operational in each region. Pg. 37 The Commonwealth plans to end out-of-home planned respite, thus risking noncompliance with the settlement agreement terms. Pg. 37 The Commonwealth has made progress in developing risk triggers and thresholds, but significant challenges remain to develop and implement a complete list. Without an adequate list of triggers and thresholds, the potential for harm to individuals with ID/DD will likely not be identified early enough to prevent actual harm. Pg. 46 DBHDS claims changes to existing incomplete list of risk triggers and thresholds will require regulatory change, which historically has taken years to accomplish. Pg. 46 Currently there is no process in place to prevent the hire of known abusive, neglectful or exploitative staff. Even APS is unable to share this information, and nothing prevents known abusive or neglectful staff from moving from one provider to another. Pg. 56
Between November 2011 and October 17, 2013, seven individuals who had moved from the Training Centers died. Six of them died during this review period. Of those six deaths, four

were from significant health issues, and two were unexpected and currently under investigation. Two other individuals suffered serious injuries requiring ongoing medical attention. Pg. 13
*Summarized except where indicated by quotation marks. Emphasis added. Full report available on DBHDS website. Provided by Training Center Family Organization Presidents: Jane Powell for CVTC (pashabean@verizon.net); Jane Anthony for NVTC (janthonyjane@comcast.net), Lorraine Koury for SVTC (lmkoury@verizon.net) and Wanda Robinson for SWVTC (theredhead@embarqmail.com).