The Maryland attorney general's Medicaid fraud control team is investigating LifeLine Inc., the state contractor that managed a group home for disabled foster children where a 10-year-old Baltimore boy died last summer.
Five people who have direct knowledge of the investigation told The Baltimore Sun that Medicaid fraud investigators have been examining whether LifeLine's Laurel-area facility was appropriately staffed with nurses for children who require around-the-clock care.
They said investigators are examining LifeLine's staffing levels, the qualifications of nurses and other business practices. Most requested anonymity because the probe is continuing and they are not authorized to speak about it.
Maribeth Donohue, a guardian for a former LifeLine resident who was hospitalized last year for an infected bedsore, said Medicaid fraud investigators contacted her in January about the company. She filed a lawsuit earlier this month on behalf of the resident, 19-year-old David Davis.
Another person who was contacted by investigators in January said their questions centered on how many nurses were working at the homes, as well as on food supplies and cleanliness.
"They are looking for any and all information about the business practices of LifeLine," said the person, who provided care to LifeLine residents and spoke on the condition of anonymity because of concerns about jeopardizing future jobs.
A spokesman for the attorney general's office would neither confirm nor deny that an investigation was underway.
LifeLine officials did not respond to requests for comment. The Baltimore-based company's chief executive said last year that she was disbanding the children's group home operation because state funding was inadequate.
A Sun investigation revealed that staffing shortages, fiscal mismanagement and deficient medical care were recurring problems for LifeLine. The state awarded the company about $18 million in contracts since 2010 to operate homes for disabled adults and foster children, despite its problems, including a founder imprisoned for arson, unpaid taxes and a bankruptcy filing. Regulators also were unaware of police reports of abuse and neglect.
Nancy Grimm, the former director of Maryland's Office of Health Care Quality, which regulates such group homes, said that, based on her experience, investigators typically try to determine whether patients received the services that Medicaid paid for.
For example, investigators will likely examine whether LifeLine provided proper staffing to meet the needs of paraplegic and quadriplegic children who rely on tubes to eat and breathe, said Grimm, an attorney now in private practice. In addition, investigators examine whether less qualified — and less expensive — staff were providing services that registered nurses should have been delivering, she said.
Staffing and training issues were cited in a lawsuit filed Feb. 11 on behalf of Davis, who was hospitalized for three weeks last May for a bedsore infection that had spread to his bones. The lawsuit cited allegations by a LifeLine nurse that the Laurel-area group home was not properly staffed on the July night 10-year-old Damaud Martin died.
Such questions about staffing and training are typical in a Medicaid fraud investigation, said Dennis Jay, executive director of the Coalition Against Insurance Fraud, a Washington-based nonprofit. The national group of insurance companies, regulators and consumers helps to detect and deter fraud through research and training.
Jay said investigators generally "chase where the money is going."
Investigations by the Medicaid Fraud Control Unit have recovered $54 million over the past two years, according to David Nitkin, a spokesman for the attorney general's office.
In its report for the fiscal year that ended June 30, the fraud unit said it was involved in 234 ongoing probes. The unit has existed since 1978 but was strengthened by a 2010 law that encouraged whistle-blowers to bring cases to the state. The unit closed 89 cases in the fiscal year that ended June 30, including 54 prompted by whistle-blowers.
In one settlement, the state and federal government recovered $750,000 from the nonprofit Foundation Health Services, which failed to follow appropriate protocols for handling bedsores and infections, mishandled medications and did not "employ a sufficient number and skill-level of nursing staff to adequately care for the residents," according to the annual report.
Foundation Health Services operated facilities in several states, including Ravenwood Nursing and Rehabilitation Center, a Baltimore home that was closed in 2012. The parent company did not admit wrongdoing, but agreed to a five-year monitoring program with federal health regulators.
Donohue and others complained about LifeLine's care last year.
Donohue's complaint to state regulators in May prompted an inspection by the state Office of Health Care Quality that found LifeLine was not providing sufficient staff to protect the "health and safety" of its young residents. Inspectors also said LifeLine's nurses were not providing adequate care to Davis.
An earlier inspection from February stated that LifeLine had failed to properly administer medications and food, and that a quadriplegic had been left in her urine and feces.
After the May inspection of Davis' condition, state regulators told LifeLine chief executive Theresa Martin that they might close the Laurel facility. She responded by saying she would shut down LifeLine's children's program, because state funding — about $11,000 per month per child — was insufficient to provide adequate care.
Before the remaining nine children living at the home could be moved, Damaud died on July 2. The nurse caring for the boy that night said she was the only nurse caring for three disabled children who breathed through tubes and had care plans that called for a one-on-one staffing level.
A state investigation found mismanagement in the boy's care — including conflicting orders to take extraordinary measures to save him or to let him die if he suffered a life-threatening condition — but ruled that LifeLine did not play a role in his death. The state medical examiner ruled the death a homicide caused by complications from head trauma Damaud suffered when he was abused in 2008, before he arrived at LifeLine.
Damaud's death was not the first at a LifeLine facility. In 2011, regulators shut down the company's homes for disabled adults after three residents died. The state allowed LifeLine to continue operating homes for children because it did not find problems with their care at the time.
Since The Sun's investigation was published, state officials have proposed reforms to improve oversight of group homes for medically fragile foster children. The Department of Human Resources, which awards group home contracts, has implemented new financial monitoring aimed at spotting fiscal problems before they affect the quality of health care. The Department of Health and Mental Hygiene, which monitors medical care at the facilities, is scheduled to implement a similar system in April.
In January, the state also hired a company to assess staff training at the three remaining contractors that manage group homes for disabled foster children. There are currently about 40 children in those homes.
Most of them live in homes managed by Second Family, a Landover-based nonprofit.
On July 3, the state moved LifeLine's remaining eight children to Second Family's homes in Prince George's County. Three weeks later, health inspectors found that nurses caring for the children there were not properly trained. Four of the LifeLine children were taken to emergency rooms after the relocation. Inspectors cited Second Family for failing to train the nurses and for failing to inform regulators about the hospitalizations as required.
Second Family has since corrected the training issues and has been found to be delivering adequate care, state officials have said.
At a Jan. 28 hearing before a state Senate committee, Deborah Ramelmeier, Maryland's acting executive director of social services, said the untrained nurses referred to in the citation had actually been LifeLine nurses who had moved over to Second Family.
That raised alarms among some advocates, who questioned how the nurses could not have been properly trained in the care of LifeLine children.
Given that there were only eight children to be moved, the state should have done more to ensure the adequacy of care they would receive at the new facility, Joan Little, chief attorney for the Maryland Legal Aid Bureau's Baltimore child advocacy unit, said after the hearing. She questioned how the state could have missed training lapses in nurses who had already been caring for the children at LifeLine's group home.
Health inspectors from the state Office of Health Care Quality conducted several unannounced inspections of LifeLine between late May and July 3, when the children were moved, and reported no problems. The office could not say how many inspections were conducted because such data is not tracked, said spokesman Christopher Garrett.
Melissa Rock, child welfare director for Advocates for Children and Youth, said the new information about the nurses "does raise grave concerns" that state health inspectors did not look at the nurses' training in the six weeks between Davis' hospitalization and Damaud's death.
"I still have concerns about accountability," Rock said.
Grimm said the training issue is likely to be critical to Medicaid fraud investigators.
"Staff must be competent to perform the tasks required," Grimm said. "Nonlicensed staff may not perform certain nursing tasks. ... The investigators may look to see if staff were being shared between homes, whether licensed practical nurses were substituted for registered nurses, and whether there was an on-call supervising RN available for emergencies."