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State's lax oversight puts fragile children at risk

Juvenile DelinquencyDeathLaws and Legislation

There were warning signs in the months before 11-year-old Arthur Lee Wiley became deathly ill.

The severely disabled boy was kept in bed so long he moaned in pain. He suffered a broken leg for reasons no one has ever determined.

By February 2002, his physician and child welfare workers had grown increasingly worried that the boy wasn't getting the care he needed at a group home for foster children in Randallstown. On March 4, the caseworkers asked other facilities to take Lee, who had cerebral palsy. But it was too late.

The next day, he was rushed to the hospital with a 105-degree fever. His temperature soared to 108 degrees. People who had grown close to the boy called Lee or "Smiley Wiley," a nickname reflecting his sunny disposition, were shocked that he might die.

"He was a medically fragile child, yes," said Christine Bory, who served as Lee's surrogate parent during school planning meetings. "But terminal? No."

His death two weeks later should have prompted an investigation by the Department of Human Resources, in accordance with its policy. But it did not. The only inquiry was a response to his school's complaint about his care - so cursory that no effort was made to determine whether he had been neglected at the home.

The regulatory breakdown in Lee's case illustrates a broad failure by the state to protect the interests of 2,700 youths who live in 330 privately run homes in Maryland. The state licenses and funds the facilities but does not routinely hold them accountable for the quality of care they provide - putting children at risk.

"It's a scandal waiting to happen," said David B. Mitchell, the former chief Juvenile Court judge in Baltimore City Circuit Court, who still hears cases. Monitoring is so poor, he said, that orphanages may have provided better care than some group homes that replaced them.

"We know what's happening," he said. "We're not properly funding, staffing and monitoring."

The Sun has documented the state's failings by systematically examining the regulation, spending and care at 25 companies that ran 120 homes, a sampling of more than a third of the total.

Reporters interviewed 150 group home staff members, doctors and nurses who treated the youths, and social workers and advocates assigned to their cases. They studied 15,000 pages of medical reports, case files and a decade of group home records obtained under the state's Public Information Act. And they consulted with lawyers, social workers and other experts.

The Sun's investigation found that:

  • Children suffer abuse and neglect in the absence of strong state oversight. At poorly run homes, substandard care and mistreatment included lack of medical treatment; scanty food, clothing and supplies; staff shortages; and assaults by employees and residents. Regulators often license unqualified operators and then largely rely on them to police themselves. Homes escape scrutiny by ignoring requirements such as reporting a serious injury. Supervision has been so lax that children were injured because counselors weren't present or paying attention. At a few group homes, police have investigated allegations that boys were having sex with prostitutes or other women brought there by employees. Staff members at several group homes have been accused of furnishing drugs and alcohol to residents.
  • The Department of Human Resources has reports on 15 deaths of group home children since 1998, as far back as its files were available. But there is no way to be sure that the circumstances were investigated or that all deaths have been recorded. For example, Lee's death isn't in the files. The department's files show that one child died of complications from cerebral palsy, another from a viral infection. Two girls were found not breathing; two others died after being hit by a car. One boy died in a head-on collision with a dump truck after stealing a car; another fell from a van. One girl committed suicide. Six children were murdered, none in a group home, most after running away.
  • Unqualified or unfit caregivers are hired because the state does not enforce training requirements and leaves screening to the operators. Even people with criminal convictions can - and do - work at group homes. In some cases, regulators have no knowledge of their backgrounds; in others, state rules tolerate certain criminal histories.
  • The state pays $157 million a year to group homes but does not make quality of care a factor in setting rates. Poorly run homes can get as much as or more than model operations - an average of nearly $60,000 a year per child. Owners can collect high salaries, enjoy expensive perks and reward friends and relatives with lucrative jobs or contracts - regulators don't check spending. The owner of Evershine Residential Services Inc. in Baltimore County, for instance, expensed luxury sport utility vehicles and cruises.
  • Children are sometimes placed in homes that can't meet their particular needs, such as intensive mental health care. Regulatory shortcomings allow the proliferation of poor-quality homes, and the state doesn't encourage development of a spectrum of facilities and services. Lax oversight has long been a problem - the growth of group homes has outstripped the state's ability to oversee them. In 2001, a task force created by Gov. Parris N. Glendening found the system so flawed that it called for a major overhaul. But few recommendations were adopted. That same year, General Assembly auditors faulted the Department of Human Resources for not making sure that the homes properly spend taxpayer dollars. Last month, a legislative audit found similar lapses. Over a two-year period, the department had not reviewed any of the homes' spending reports to the state. At stake is the well-being of Maryland's most vulnerable children. Human Resources, along with the Department of Health and Mental Hygiene, takes custody of kids because parents abused or neglected them or couldn't cope with the demands of their care. If no foster families are available, the children go to group homes distinct from those licensed by the state for disabled adults. Youths who have broken the law are placed in group homes by a third state agency, Juvenile Services. "These children have special needs that go way beyond basic," said Sarsfield Williams, executive director of Aunt Hattie's Place, a well-regarded company with facilities for 18 boys in Baltimore and Randallstown. Defending the state's oversight, officials say they don't tolerate inappropriate spending or unqualified caretakers. They say their inspectors keep tabs on the facilities and punish violations of rules. Christopher J. McCabe, secretary of the Department of Human Resources, said the examples uncovered by the newspaper should be viewed as exceptions. "I don't think it's fair to condemn the whole system, as you do in your analysis, because of some homes you focus your attention on," said McCabe. His department oversees the majority of group homes, with eight inspectors to review 198 homes serving 2,400 children; they are also responsible for overseeing more than 100 adoption agencies and other licensed programs. In a news release last week, McCabe said, "We are serious about making sure that children living in DHR-licensed group homes have a safe and nurturing environment. We are serious about putting children first in Maryland, and our kids in group care deserve a good quality of life, just like every other kid does." Responding to the latest legislative audit, he said the department will review group-home spending. The state blames limited funding for delays in making some improvements. Officials described changes in the works, such as computer databases intended to show the locations, capabilities and capacities of homes, and others recently implemented. As of Jan. 1, the three agencies that license group homes are required to act on complaints within 24 hours and follow up on homes' promises to fix deficiencies. The new regulations also expand punishable offenses to include lying to state regulators and bar homes from employing people who have recent convictions for drug offenses. Child welfare advocates see the changes, made in response to the 2001 task force, as minimal. Effectiveness, they say, depends on enforcement, and the state has a spotty record of enforcing rules already in place. State officials point to successes in shutting down bad operators: In the past five years, the state has put 11 group home companies out of business. But foot-dragging and legal delays can prolong that process, imperiling children. In Talbot County, inspectors began flagging violations at Bethany House Inc. as early as 1990. Over the years, among other things, they noted cockroaches in the kitchen, a toilet that didn't work and feces-smeared walls. In 2000, 12 Bethany House residents assaulted a counselor and another resident in a robbery attempt, prompting the Department of Juvenile Services to stop placing boys there. In 2001, the Department of Human Resources renewed Bethany's license despite county reports that youths and staff were using marijuana. The state did not start shutting down its three homes in Talbot County until 2002, after a boy sodomized a younger resident. Bethany is not taking care of any foster children, but it hasn't lost its license. An appeals court overturned the license revocation last August, saying that the state had violated due-process rights. It took three years for the state to close Sunrising Group Home Inc. in Baltimore County despite repeated indications of mistreatment. In April 2000, a social worker complained that a boy had been bruised by a staff member restraining him. Later, inspectors found that girls were eating breakfast on the dining room floor and staff members hit boys. An inspector wrote in February 2002 that "children are at great risk for their safety." The state waited nine months to take action against the company's license. In upholding the closing of Sunrising in 2003, an administrative law judge observed that the state relies on "a relationship of trust" between its regulators and the homes. Camille Wheeler, who was director of Baltimore County Department of Social Services from 1979 to 1998, criticized the honor system. "It's all built on the premise that everybody is trying to do good and thus you don't expect people to do bad." But Wheeler said it doesn't always work that way: "Profit gets in the way, and it's human nature to hide your mistakes." In May 2000, Rockville-based Grafton Maryland Services didn't tell the health department when a boy at one of its group homes drank Pine Sol cleaner and required treatment for a half-inch cut to his scalp after falling, state records show. The company pledged to revise its reporting policy and train its staff. But two years later, Grafton again failed to report an injury. A 17-year-old boy ran away in June 2001 from a home operated by REM Maryland Inc. of Towson, but REM didn't tell the health department as required, according to state documents. Company officials later promised to report all incidents. Likewise, Family Solutions in Beltsville didn't tell the health department that police investigated child sexual abuse involving two staff members in July 2003. The incident came to light the next January during an inspection, records show. The company pledged to report any serious incidents in the future. The cases of three children documented by The Sun illustrate different ways in which regulatory lapses prevented the state from fulfilling its role as protector.
  • Regulators failed to investigate Lee Wiley's death or even include it in their official record of child deaths.
  • Jennifer McLaurin was put in a group home that, by its own admission, couldn't cope with her suicidal tendencies and asked repeatedly for her transfer. Her death was an example of the placement problems that critics say are common to the system, yet it prompted no action.
  • Keyyon Makins was killed after running away from an abusive counselor, mistreatment the state learned about from Sun reporters, not from his group home.Arthur Lee Wiley: A fragile boy If the Department of Human Resources had followed its policy and investigated the death of Lee Wiley, it would have discovered documented concerns about the care he was getting at the Place for Children. The only scrutiny of the home came after a complaint by a guidance counselor at Lee's Maiden Choice School, a public school in Arbutus for children with profound disabilities. As Lee lay dying in Sinai Hospital in March 2002, Keith R. Niemeyer said he called the governor's office because he felt the group home might not have taken Lee to the hospital promptly enough: "If he came into the hospital with a high fever, was it appropriate to have taken him earlier?" A department inspector, Ertha Sterling, interviewed school personnel, Lee's caseworker and the group home director. But even after being told that Lee's doctor and lawyer were concerned about his care, she did not interview anyone else. She chose not to look into the circumstances of his death. In a memo to her boss written two months after Lee died, Sterling cleared the home of any possible violations of regulations. When The Sun questioned the department about her approach, she responded with another memo to supervisors: "There did not appear to be a need to investigate Arthur's death since there was no concern that his death was due to any reason other than complex medical problems." Yet when The Sun questioned the department about Arthur Lee Wiley, spokesman Norris P. West replied, "All fatalities of children in care are investigated." Children's advocates say the state needs to conduct thorough investigations of deaths and other incidents to ensure that homes provide high-quality care. "It seems so basic to me," said Cathy Surace, an attorney at the Maryland Disability Law Center, a nonprofit designated by the state to advocate for the developmentally disabled. "That's the only way we can protect the people we put in these homes." In Lee's case, medical experts interviewed by The Sun said the vigilance and skills of his caretakers at the home were crucial. Lee couldn't walk, talk or feed himself, receiving nutrition through a stomach tube. There were several causes for concern about his care, starting with how staff at the group home moved him. United Cerebral Palsy of Central Maryland guidelines for its programs specify that two employees should lift children weighing more than 40 pounds. Lee reached a weight of at least 71 pounds. But his counselor and a private nurse hired to look after him overnight said in interviews that they carried him alone, even on stairs. "We usually just threw him over our shoulder and walked right down," said the nurse, who asked not to be identified. In January 2001, the group home agreed to look into acquiring a mechanical lift to carry Lee up and down the stairs to his bedroom, licensing files indicate. None was installed. JoAnne W. Elliott, executive director of the home, declined to comment on Lee's case, citing confidentiality concerns. In a letter to the Department of Human Resources, she said she didn't purchase a lift because he might be adopted. But he lived there another year. By October 2001, concerns about Lee's care were mounting, according to public records and interviews with doctors, educators and relatives. In pain and crying, Lee was sent by his pediatrician, Dr. Eric B. Levey, to the Kennedy Krieger Institute in Baltimore to determine why. On Oct. 23, Dr. Frank S. Pidcock diagnosed skin sensitivity and muscle tightness. Lee had been kept in bed too long. "Children with cerebral palsy need daily care, which consists of stretching and positioning," Pidcock said in an interview. On Feb. 11, 2002, Lee's counselor at the group home found a red mark on his right leg. Hospital X-rays revealed a fracture. The hospital contacted social services officials, who notified police, a step often taken when foster children are injured. The Place for Children told an investigator that the injury occurred at Lee's school; the school said he had arrived there in pain. Police said they couldn't pinpoint the origin of the injury. At about that time, Lee's caseworker and her supervisor at the Anne Arundel County Department of Social Services were alarmed. "There are concerns that his needs are not being met adequately. He is not receiving the proper physical therapy," wrote Martha Smith and Dee Loftis in a departmental memo as they prepared to search for a new group home. Later that month, Lee's pediatrician, Eric Levey, said he should be moved to another facility. "He feels a Place for Children is over their heads in caring for a child as complex as Arthur," the caseworker wrote. "I was worried they may give him the wrong medication," Levey said in an interview. "I was worried they may not pay attention to him if he got sick." On March 5, a group home counselor, Veronica Fox, said she noticed that Lee wasn't acting normally. His temperature measured 105 degrees, Fox said. She and the overnight nurse gave him Tylenol and a cool bath. But his fever didn't subside. At Sinai Hospital, he didn't have a palpable pulse, records show. Infection was spreading throughout his body. When informed he was dying, his mother, Sandra McKinney, and other members of his family rushed to Sinai. After keeping him alive with a ventilator, doctors concluded that his brain had been damaged and he wouldn't recover. On March 21, 2002, with a judge's permission and McKinney's concurrence, they disconnected life support. "I didn't want him to be a vegetable," McKinney said in an interview. "He had been through enough." She and Lee's older sister, Stacy Smith, couldn't understand his rapid decline. "He was very healthy for a medically fragile child," Smith said. The Department of Human Resources should have filed an internal report, according to its own policy. The reports are supposed to provide the official record on deaths in children's group homes. But there isn't one on Lee. "I don't have a report on that," West said.Jennifer McLaurin: A girl in distress Within weeks of arriving at a Wheaton group home in July 2001, Jennifer McLaurin tried to commit suicide by drinking half a bottle of lotion. Over several months, there were more attempts, threats to kill herself and hospitalizations. The home's furniture, windows and household cleaners were potential instruments of self-destruction. But the Baltimore City Department of Social Services couldn't find a more appropriate facility. And she couldn't stay at home with her mother, not in her condition. Jennifer's story illustrates a serious shortcoming in the child welfare system: Regulators haven't developed enough good options for foster children. In their licensing role, they haven't encouraged the growth of the range of services needed to meet the kids' needs, child welfare experts and veteran social workers say. In addition to group homes, the experts say, there should be facilities that offer more intensive care. But there aren't, for example, many residential treatment centers offering the most intensive mental health therapy. Instead, for many children Maryland offers a stark choice between foster families or group homes. If foster families can't or won't take a child, the youth is left to go to a group home. And there aren't enough high-quality ones. Local social services agencies, which place children, must make do with the options they have. Gloria Slade saw this while supervising the child placement unit at the city Department of Social Services. "There were some providers who were good, but there were others who we would have chosen not to be bothered with, but we had no choice," said Slade, who retired in 2001 and now runs a group home. Jennifer didn't belong in the home run by Silver Spring-based Brotherhood and Sisterhood International. Group home director Carolyn Kennedy says that quickly became clear to her. City social services workers didn't fully inform her, Kennedy says, of Jennifer's condition. Then they failed to find a more appropriate facility, despite repeated requests. "They kept saying they didn't have a place for her," she said. Meanwhile, one suicide attempt followed another. Finally, on April 21, 2002, a counselor at the home let Jennifer take a bath and then dress alone, the facility wrote to the health department, which licenses Brotherhood. Ten minutes later, the 14-year-old was found in her bedroom closet, hanging by a head scarf. Experts who reviewed Jennifer's case at The Sun's request said the girl's behavior should have made it obvious that she needed more intensive services. "You can never totally do something to prevent a suicide, but the suicide attempts, the hospitalizations, all the signs were there, and the right steps were not taken," said Linda Koban, who oversaw foster child cases as a Juvenile Court official. "She needed to be in a residential treatment center." In a suit filed in Prince George's County Circuit Court against the state and Brotherhood, Jennifer's parents, Tonya and Jonathan McLaurin, cited the state's "failure to place Jennifer into an appropriate residential environment," among other things. The suit underscores the state's dual regulatory role: In addition to monitoring care, officials are required to provide appropriate placements for children. The state health department confirmed that Kennedy promptly asked the city social services agency to move Jennifer. But health officials criticized Brotherhood for misstating its capabilities in Jennifer's case, without sanctioning the company. "We did not misrepresent ourselves in any way," said Kennedy. "The system inappropriately served her because it didn't provide the residential treatment she needed when we identified her as needing this kind of treatment. The system is not designed to serve her; there is a gap." As a result of The Sun's inquiries about Jennifer's case, the health department later scrutinized Brotherhood's operation and barred it from accepting new residents until it makes improvements. Among other things, the company must assess residents to determine if they're a risk to themselves or others, and to develop psychiatric plans for those who show signs of dangerous or high-risk behaviors. The state's regulatory structure precluded any investigation of the caseworker's decision to place Jennifer at Brotherhood and keep her there. A health department official said it lacks authority to investigate social services because they're part of another state agency, the Department of Human Resources. City social services officials declined to comment.Keyyon Makins: An orphaned youth As he entered the group home on Dec. 31, 2003, Baltimore County Police Officer Keith Gordon heard screams. The officer had been investigating a report of kids making false 911 calls from stolen cell phones and had gone to the house to talk to residents. Going upstairs, he found a terrified 14-year-old boy. Keyyon Makins was on his back, pinned to a bed by a staff member, the officer wrote in a report. The counselor was astride Keyyon. Her left hand was "pressed into victim Makins face forcing his head back and off the edge of the bed," the report said. "Her right hand was drawn back in a fist and she was screaming at victim Makins." The officer ordered the counselor, Shantelle Diggs, off of the boy, Gordon testified later at Diggs' trial on assault charges. Keyyon got off the bed and moved away along the wall "cowering," "sobbing" and "covering his face with his hands." As the boy crept away, Diggs "struck Keyyon across the back of the head," the officer testified. "From the way his head came forward and the way his body came down," Gordon said, he knew it was a hard blow. "She's always hitting," Gordon said he heard Keyyon say before the boy fled the Woodlawn home, owned by Evershine Residential Services Inc. Keyyon's case underscores the limitations of regulators' reliance on group homes' good faith. Regulators effectively trust the homes to report serious incidents, spend their funding as they had budgeted, hire and train qualified staff, and take good care of the youths. The regulators "are dependent on people being professional and doing the right thing," said Susan Daddio, a former group home director who is executive director of Court Appointed Special Advocates of Baltimore County, whose volunteers advocate for foster children in court. "It's a very broken system." Rules require a home to report runaways, assaults and other incidents involving the police within 48 hours to its state licensing agency and the child's caseworker. Officials at Evershine, Keyyon's group home, say they immediately notified police and city social services that Keyyon had fled, and they told Human Resources within a week after gathering all the facts. But Keyyon's case files at city social services show that Evershine waited five days, three more than allowed. Merely saying Keyyon had run away, the group home omitted that a counselor had assaulted him. The only report from Evershine that Human Resources could furnish The Sun was dated Jan. 29, four weeks after the assault. It was faxed to the department on Oct. 20, after the newspaper had asked the department for a copy. The two-page report did not mention the assault. Four Evershine employees told reporters that management discouraged them from reporting serious incidents. "They covered it up," said Kim Branch, a former Evershine counselor. While Evershine immediately fired Diggs after her arrest, the company's assistant executive director, Bonnie Meeks, told a District Court judge during trial that the home would rehire her if she were acquitted. The judge found Diggs guilty of second-degree assault, sentenced her to 30 days in the Baltimore County detention center and fined her $1,000. Then he suspended both the sentence and fine and placed her on a year of unsupervised probation. She didn't return to the group home. "I just think that this day she got ticked off and she snapped," said Judge J. James McKenna, a retired Montgomery County Circuit Court judge assigned the case. He told Diggs at sentencing: "I'm hoping that if you do get involved with children again, that you'll take this as an opportunity for you to count to 10 before you start swinging away or jumping on anybody." Keyyon had entered foster care after his mother and father died of HIV-related illnesses and his grandmother died of a drug overdose, according to his case files. After fleeing the group home, Keyyon took buses to Cherry Hill, home to his few remaining relatives. Keyyon's aunt, Theresa Matthews, said she immediately called Evershine to come get him, "but they never did." Evershine officials said they wouldn't send staff members to look for him out of concern for their safety in a rough neighborhood, and they saw it as a police responsibility. A brief search by Rhonda Apooyin, Keyyon's city social services caseworker, on Jan. 20 - three weeks after he ran away - ended unsuccessfully, according to the case files. Shortly before 3 a.m. on Jan. 28, relatives say, Keyyon and some friends went to a nearby house to buy some cigarettes. They encountered a man, Kenneth Worrell, who police say stabbed Keyyon in the neck. Keyyon was found lying in the snow at the end of a 100-yard trail of his own blood. Worrell later told police he was afraid that those who came to his door were members of an armed gang that had robbed and beaten him that evening. He has pleaded not guilty to murder and is to go on trial in May. Keyyon's sister and two brothers blame Apooyin and city social services, which placed him at Evershine. "He was their responsibility," said Lanay Young, Keyyon's sister. "They didn't look after him like they were supposed to." Even though Evershine didn't report the assault on Keyyon and waited to report his flight until after his murder, the Department of Human Resources did not punish the company. Told about Keyyon's case in October, DHR Secretary McCabe said it warranted an investigation. "It's intolerable and unacceptable if true that in a group home, a child was assaulted," he said. "That in itself would be something that I take exceptionally seriously and would want to investigate fully." His agency has not responded to questions whether an investigation took place. Evershine defended Diggs as a good counselor who built a rapport with Keyyon, a difficult, argumentative boy who frequently ran away. Said Joseph K. Skariah, the executive director of Evershine: "We have done whatever we could do for him." "I think we offered him more than most placements he was in," said Meeks, the assistant executive director. "I think he felt loved here."
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