Report on the Massachusetts Department of Mental Retardation : an investigation by the House of Representatives Post Audit and Oversight Bureau including "Are you sure about this guy?" an analysis of the abuse of two mentally retarded men in Raynham, Mass

166 Pages·1997·7.7 MB·English

by  Massachusetts. General Court. House of Representatives. Post Audit and Oversight Bureau

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2013
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The General Court of Massachusetts
OCT 1 5 1997
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Report on the Massachusetts Department ofMental Retardation:
An investigation by the House ofRepresentatives Post Audit and Oversight Bureau
including
"Are you sure about this guy?"
An analysis ofthe abuse oftwo mentally retarded men in Raynham, Massachusetts.
The House Committe on Post Audit and
and the
Post Audit and Oversight Bureau

.
TABLE OF CONTENTS
I. Problems with Investigations and Monitoring 3
II. Executive Summary 5
Findings 10
III.
IV. Recommendations 27
V. The Raynham Case 30
VI. Investigations and Monitoring 69
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VII. Mortality of Clients 74
VIII. Attachments 86
1 Case Studies 86
A. Halifax 86
B. North Reading 90
C. Waltham 107
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2. and DPPC Regulation Overview 111
3. Commissioner Morrissey's Letter ofResponse to the Bureau Report 125

DMR INTERIM REPORT
PROBLEMS WITH INVESTIGATIONS AND MONITORING
T.
Preface
The House Post Audit and Oversight Bureau's multi-year review ofthe
Department ofMental Retardation shows an agency that has lost sight ofits mission and
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needs to get back to basics such as focusing on the health and safety of clients. The
Bristol County Probate Court has already placed a component ofthe agency's services
under a limited receivership.1 The Bureau's most recent review ofDMR's operations in
the context ofthe Raynham case causes it to have grave doubts about the Department's
commitment to the basic health and safety issues and ensuring that community
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placements provide equal or better care for clients.
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The Bureau's comprehensive review of found serious problems in every
major area that it examined. In addition to problems with investigations, abuse, client
mortality, changing data, management and communications deficiencies, the Bureau
found employee morale and sense ofpurpose to be poor. In some cases, employees of
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were disciplined for essentially adhering to policies of executive
management. In other cases employees were demoted and even harassed when they
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attempted to voice legitimate concerns about policies and programs.
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The Bureau's review of met a number ofobstacles. In addition to changing
data and numbers, many ofthe Bureau's requests for information were met with
unnecessary and inexplicable delays and in some cases, obstruction. In many cases it
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appeared that used client confidentiality as a means to obscure the facts.
This report and its multiple appendices and case studies present a disturbing and
critical look at DMR. The report's conclusion is that the new commissioner needs to
institute an immediate top-to-bottom management review ofthe entire agency. To assist
See JudgeRotenbergEduc. Center, Inc. v. Commissioner ofDep7 ofMentalRetardation, 424 Mass. 430
(1997).
in this review, the commissioner should consider the appointment ofan independent
management consultant to focus on issues including investigations, communication and
cooperation within and outside the Department, as well as a return to basics such as the
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health, safety, and welfare of clients.
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The Bureau notes that its investigation of involved a substantial period that
in large part was under the control ofprevious commissioners. The Bureau
acknowledges that since the appointment ofCommissioner Morrissey in 1997, there have
been substantial improvements in cooperation. The new commissioner has met with the
Chairman and staffto address the legitimate issues that have been raised. The Bureau is
confident that the Committee can work effectively with the Commissioner in his role as
the principle policymaker in mental retardation issues.