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8/13/2019 Important Negative Findings of the Independent Reviewer - 3rd Report
1/1
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 eventsyet 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. 31Crisis 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
significantchallenges 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 unde
investigation. Two other individuals suffered serious injuries requiring ongoing medica
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 ([email protected]);
Jane Anthony for NVTC ([email protected]), Lorraine Koury for SVTC ([email protected])and
Wanda Robinson for SWVTC ([email protected]).
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]