The disabled foster children removed from a troubled Laurel-area group home this summer were placed by Maryland regulators in facilities whose their nurses lacked training for their complex medical needs, inspection records show.
Health regulators did not learn of the training lapses — including the inability of some nurses to change breathing tubes — until they conducted an inspection nearly three weeks after moving the children. Officials were also unaware that half of the eight children ended up in emergency rooms shortly after being placed at the Prince George's County facilities operated by Second Family, the state's largest contractor for around-the-clock residential care for such children.
The Landover-based nonprofit was cited for violating state regulations that require contractors to report such hospital visits, for failing to properly train nursing staff and for neglect of a disabled child, according to July and August inspection records obtained by The Baltimore Sun through a Public Information Act request.
"These reports look terrible," said Nancy Pineles, managing attorney for the Maryland Disability Law Center. "These kids are depending on these staff for their lives."
The problems raise new questions about state oversight of the children, who suffer from conditions that can require breathing and feeding tubes. A Sun investigation has highlighted problems at both the Laurel-area apartments run by LifeLine Inc. — where 10-year-old Damaud Martin died July 2 — and the Second Family homes. The investigation, which revealed that regulators were unaware of problems at the homes, sparked reforms and a continuing examination of the regulation of such homes.
Second Family's president, Shilda Frost Labule, did not respond to a request for comment. A routine inspection in September by the Department of Human Resources showed that the company had corrected most of the issues related to the "huge influx of new employees in July" that was "due to emergency transfers from a defunct provider," a report states.
Still, some advocates questioned why the state moved the children before Second Family's homes were ready for them. State Sen. Joan Carter Conway also questioned why a contractor paid by the state to house medically fragile children employed staff who lacked proper training.
"It wouldn't make sense," said Conway, a Baltimore Democrat who chairs the Senate committee that handles health issues. "If I'm providing the care and you're paying me millions, how did I get my license and certification if my personnel and staff don't have appropriate training?"
Maryland Health Secretary Dr. Joshua M. Sharfstein released the inspection reports to Conway and Del. Peter Hammen, a Baltimore Democrat who chairs the House's health committee, along with a letter co-written with Department of Human Resources Secretary Ted Dallas. The health department licenses group homes and inspects health services; Dallas' agency awards contracts and evaluates providers.
The two secretaries released the records as part of an ongoing review they announced at a July 24 legislative briefing in Annapolis. The meeting was spurred by the Sun's investigation, which revealed years of problems with LifeLine.
The state had awarded about $18 million in contracts since 2010 to LifeLine despite deficiencies in medical care, a founder imprisoned for arson, unpaid taxes, a bankruptcy filing, and police reports of abuse and neglect unknown to regulators. In 2011, regulators shut down LifeLine's homes for disabled adults after three residents had died, but allowed the firm to continue operating homes for children.
At the briefing on July 24 — the same day health inspectors were discovering the emergency room visits and lack of training at the children's new homes — Sharfstein and Dallas told lawmakers they were comfortable with Second Family and two other smaller contractors that provide such services. "As far as I'm aware," Sharfstein said at the time, adding that he had asked his inspectors to "take a much closer look."
But The Sun revealed in October that Second Family had its own questionable management issues — none of which were mentioned at the hearing. The nonprofit, which has been awarded at least $69 million in state contracts since 2002, fired two employees in January for slapping, kicking and pushing a mute, autistic child. Another employee was fired July 16 after a disabled child rolled off a bed whose side rail had been left down; the child suffered injuries that required a hospital trip and inspectors cited Second Family for neglect in a July 18 report.
The recently released inspection records from the Office of Health Care Quality raise questions about the thoroughness of the relocation process "and whether it was safe to move them all on that date," said Pineles, whose nonprofit organization is an official monitor of state care to disabled adults and children.
Asked whether state officials realized before relocating the children that Second Family's nurses lacked training, health department spokesman Christopher Garrett wrote in an email: "This type of violation is determined after a child is admitted and a care plan is set. In this case, OHCQ cited the facility for gaps in training related to the nursing needs of the newly admitted individuals."
Garrett said state officials and contractors "share the common goal of quality care for medically fragile children. Pursuing this goal has involved close follow-up since this summer."
State inspectors found 16 regulatory violations in three inspections during July and August at Second Family, which cares for 34 children.
One inspection, which took place July 23-25, "revealed that the staff had not been trained on the medical/nursing needs of the children," the report states. It found that nursing care plans for the eight LifeLine children "have not been updated."
It also cited Second Family for failing to notify state regulators about the emergency room visits by four children. Providers are required to notify the state about incidents that require a response from police, fire or emergency officials. Two of the children were admitted to the hospital for treatment. The report did not include details about the emergency treatment or where it occurred.
Second Family staff told inspectors that they had tried to report the incidents but that technical issues with the reporting system thwarted their attempts. An inspector following up on July 28 reported that "the incidents still had not been reported."
Another incident on Aug. 8 provided a stark example of how a lack of training can lead to problems for children who breathe through tracheostomy tubes connected to ventilators. The "trach" tubes connect to a surgically created opening in the child's windpipe and periodically need to be changed and suctioned free of saliva and other fluids.
A state inspection report says Second Family's chief executive told inspectors that two licensed practical nurses "froze" when a trach tube became dislodged, and were not able to reconnect it. "The staff then called 911," the report says.
The inspector's detailed, eyewitness account showed how the two nurses fumbled their way through the patient's tracheostomy care:
"Upon discovering that the Trach was not the correct size, the LPNs debated about using it until [a registered nurse] intervened telling them that using the incorrect sized trach was not appropriate," the report states. The nurses searched the entire house, including two emergency bags in a supply closet, but could not find any "extra trachs."
"Both LPNs then gloved and attempted to perform trach care and broke the sterile field on several occasions," the report states.
The inspector intervened to request that the registered nurse "immediately assign the task to another nurse to ensure the child's safety."
The report states that the two nurses signed a form saying they had attended training on July 28 — a session held in response to the concerns of regulators. "Mandatory!! All-Staff Training, Monday, July 28" reads a Second Family flier detailed in inspection records. But direct observation of a second procedure revealed that the two "were not able to perform trach care safely," the inspection report states.
"A conversation later with the executive director revealed that [the nurses] had not attended the agency's Trach and Ventilator training," the report states.
Second Family was issued a violation for lack of staff training.
Department of Human Resources inspectors wrote in September that six hospital visits had been reported in the July-to-September quarter. "Four were for reattachment of the J-Tube," the report states, referring to feeding tubes that are attached to children's stomachs. "This type of visit is routine for the medically fragile population."
In their recent letter to lawmakers, Sharfstein and Dallas wrote that their agencies continue to work together to oversee group homes for disabled foster children. Inspectors with the Office of Health Care Quality continue to "maintain close oversight" of Second Family, "including unannounced on-site inspections," the letter states.
The Nov. 21 letter noted that the agencies plan to hire a consultant to determine the training needs of Second Family and the state's two other contractors, and to ensure that the training is completed. Sharfstein is also hiring an additional employee to directly oversee group homes for disabled foster children.
"We recently determined an independent consultant could enhance the delivery of services," Garrett wrote in his email. "The consultant will provide additional education, training, and support."
State officials met with Second Family officials on Nov. 14 to discuss the organization's plans to correct the deficiencies cited in inspections. "These plans show that Second Family, Inc., is working to improve training and compliance in several areas," the letter states.
Sharfstein submitted a five-point plan last month to the lawmakers, calling for ways to improve the oversight of group homes. He also started a task force that will report by late January on recommendations for more improvements. Dallas' agency created a form that all providers must fill out to alert regulators when significant financial problems such as bankruptcy and unpaid taxes arise.
Both secretaries have acknowledged that their agencies must improve how they monitor financial problems before they affect quality of care. LifeLine experienced many of those problems throughout 2013 and this year.
Sharfstein has announced that he is leaving in January to work at the Johns Hopkins University's Bloomberg School of Public Health, so the next health secretary will have to tackle the issue.
Damaud's death may also have further legal ramifications. The state medical examiner last month ruled his death a homicide caused by head trauma that the boy suffered in 2008, before LifeLine began caring for him. His mother was convicted of child abuse after entering an Alford plea, which means she did not admit guilt but acknowledged that city prosecutors had enough evidence to convict her.
The full autopsy has not been released because law enforcement officials are still involved in a homicide investigation.