Audit: Investigations Lacking at State’s Developmental Centers

On Tuesday, the California State Auditor released a report that found several deficiencies in the Office of Protective Services' investigative procedures at state institutions for residents with developmental disabilities, the Center for Investigative Reporting reports (Gabrielson, Center for Investigative Reporting, 7/9).

Background

Last year, lawmakers began investigating OPS actions at five board-and-care institutions in Los Angeles, Orange, Riverside, Sonoma and Tulare counties that serve a combined 1,800 patients.

The facilities treat residents with conditions such as cerebral palsy, severe autism and intellectual disabilities.

Case files and legal documents from the past several years suggest that many incidents of patient abuse occurred at the five institutions, according to an investigation by California Watch, which was founded by CIR.

The investigation found that detective and patrol officers from OPS did not properly evaluate many of the cases.

According to the report, 327 substantiated patient abuse cases and 762 unexplained patient injuries have been recorded at the institutions since 2006, but most of these incidents have not led to prosecutions (California Healthline, 5/2/12).

Details of the Audit

State officials ordered the audit in response to last year's investigation.

Auditors found 54 deficiencies in police methods after reviewing 48 abuse complaints.

They also found that much of the data for 82 patient abuse cases that OPS sent to district attorneys for possible prosecution were "not sufficiently reliable" (Center for Investigative Reporting, 7/9).

In addition, the report noted that abuse cases were not promptly reported to law enforcement personnel, and that officers often failed to collect:

• Statements from witnesses or suspects;
• Photographs of the crime scenes or alleged victims; and
• Interviews with alleged victims (Sanders, Sacramento Bee, 7/10).

The report found that the state Department of Developmental Services -- which oversees OPS and the five patient centers -- has failed to address several issues raised by the auditor a decade ago, including:

• Lack of specialized training for officers;
• High turnover rates;
• Lack of a cohesive recruiting plan; and
• Increased reliance on overtime staffing (Cadelago, U-T San Diego, 7/9).

Auditors also criticized the state Department of Public Health -- which regulates the centers -- for failing to "consistently perfor[m] all of its required duties," including:

• Investigating less-serious incidents in a timely manner; and
• Promptly performing site inspections at the centers (Center for Investigative Reporting, 7/9).

Audit Recommendations

The audit recommended that DDS:

• Revise training policies;
• Add a formal recruiting program; and
• Evaluate the effectiveness of health facilities' enforcement systems (U-T San Diego, 7/9).

State Response

DDS agreed with the report's findings and said that many of the suggested changes already are under way.

DDS Director Terri Delgadillo said, "The department recognizes that despite significant progress to date, more can be done to improve the safety of individuals residing at the facilities" (Center for Investigative Reporting, 7/9).

DDS said it is working to boost training, incident reporting and OPS procedures and will immediately accept help from the California Highway Patrol to manage law enforcement personnel and implement the audit's suggestions (Sacramento Bee, 7/10).

Meanwhile, DPH agreed with most of the findings but disagreed with a recommendation to set deadlines for investigating incidents that do not involve serious risk or harm to patients (Center for Investigative Reporting, 7/9).