It was supposed to be over by now.
In 2009, the State of Texas promised the U.S. Department of Justice that it would clean up its 13 institutions for people with developmental disabilities. Those homes — called state supported living centers — would have quality medical care, offer ample social activities, help residents become more independent and move as many people as possible into community settings.
The Justice Department expected it to be done in five years.
But after eight years, $269 million and unprecedented scrutiny by state and federal regulators, Texas living centers remain in the grip of the DOJ.
Over the last year, nine of the 13 centers have had their Medicaid money threatened because of serious problems.
A Brenham living center resident died after her state caregivers left her in a hot van. In Brenham, a man died after being struck by a vehicle driven by a center employee. In Austin, a resident choked on food at a restaurant and later died. A Mexia resident ran away, stole a truck and was chased by a man with a shotgun.
Those failures underscore how the state struggles to honor its responsibility for the 3,000 residents who have profound disabilities. Lawmakers have tried unsuccessfully to close or consolidate some of the facilities, saying the centers are rife with problems and cost too much to operate.
Yet while serious problems remain, there is growing evidence that residents of the homes are safer than they have been in a long time.
Officials say the centers have made great strides over the last eight years, such as improving medical care, reducing resident injuries and moving 1,500 people from the centers into community settings. Residents are living longer, there’s a new electronic health record system, and there are fewer cases of abuse and neglect, said Health and Human Services spokeswoman Carrie Williams.
And for the first time in a decade, there may be a glint of hope that Texas can convince DOJ regulators that they are doing this work in a humane way.
“Five years was ambitious, and we knew it would take longer,” Williams said. “This isn’t a quick fix. We’re making change that is sustainable and will last.”
Still the best option for some families
Shanna Belile sits in her wheelchair at Austin State Supported Living Center, smiling and mugging for the camera.
“Cheeeeeese,” she says as the newspaper photographer snaps her picture. “Cheeeeese!”
Shanna — who greets people with a big smile and a handshake — has intellectual disabilities. Born with a severe seizure disorder, the 51-year-old woman doesn’t walk, speaks minimally, and needs around-the-clock medical care. Shanna was admitted to the Richmond center when she was 9 years old, a decision her family made after she was bullied by other children and abused by a teacher. She lived at the Richmond living center for 42 years before coming to Austin this spring to be closer to her family.
Shanna has always had a sunny personality, her sister, Liz Belile, says. But since moving to Austin, she’s even happier.
“She’s delightful,” Belile says. “She’s wonderful.”
Liz Belile is among those fighting to keep the state supported living centers open. She’s heard the stories of problems at the institutions and says her heart breaks for any vulnerable person who is hurt. But she is convinced that her sister is safer at the Austin center than in the community group homes touted by advocates.
The living centers have medical, dental, and therapy services on campus. Her sister always has caregivers with her, they provide regular activities, and security cameras help ensure that Shanna is safe, Belile said.
“I feel like she’s getting amazing care here,” she said. “I feel like my sister is loved and cared for.”
Texas’ trouble with the Department of Justice began in 2006, when — amid complaints of civil rights violations — the agency kicked off an investigation into the Lubbock facility. Two years later, it investigated the Denton center.
In 2008, DOJ launched an investigation of the remaining 11 centers and, by year’s end, the agency told the state that it was failing to protect residents. In one year, at least 114 residents had died, 53 from preventable conditions.
Federal officials found that neglected residents had ingested latex gloves and Swiss Army knives and suffered preventable injuries from seizures and falls. Medical care was substandard. Staffers had liberally used straitjackets and the institutions failed to properly report and investigate abuse.
Since 2009, the state has spent $269 million trying to fix its problems through a multi-pronged attack: $233 million for new employees, training and monitoring; $24 million for DOJ-required, independent monitoring teams to evaluate all the centers on a regular basis; and $12 million for consultants.
Violent outbursts a ‘prevailing problem’
But despite years of effort, Texas’ living centers remain firmly in the cross-hairs of federal regulators.
Between September 2016 and October 2017, federal reports show, Medicaid officials threatened to halt the flow of federal money to the facilities to nine centers a total of 25 times because of problems such as resident safety, substandard medical care, failure to address bedbugs and a lack of individual attention to residents. The Denton center has been threatened with the loss of its money seven times, Mexia, seven; Brenham, three; Abiline, two; San Angelo, two; Richmond, one; Corpus Christi, one; Lufkin, one; and Austin, one.
At the Mexia living center — which is where residents facing criminal charges are housed — violence is a common occurrence, enough so that the federally mandated, independent monitors noted it as a “prevailing problem” at the facility, according to a June report. The big problem is that residents are attacking each other — more than 100 times a month, the document states.
Meanwhile, employees have been slapped, punched, pushed and bit. Some residents are so violent that center officials have told Medicaid inspectors that they shouldn’t be at the living centers. In fiscal year 2017, staffers were injured by aggressive residents 1,111 times, a 32-percent decrease since 2014.
The cause of the violence against residents or staffers depends on the situation.
In cases noted in by federal inspectors, one aggressive resident attacked others who made loud noises. Another acted out because he wasn’t allowed to go on outings because of his behavior. Another — who punched someone just passing by — was angry because he felt like he was being supervised too closely.
“(He) said he would punch a person a day until he was on routine supervision,” according to a report documenting the incident.
Each time centers were cited for such problems, they made the necessary changes and kept their money.
Meanwhile, disturbing incidents of aggression by employees against residents continue to happen, according to reports by the Health and Human Services Office of Inspector General. Over the last year, several dozen employees have been caught punching, slapping, dragging or otherwise hurting residents.
A Lufkin center employee was charged in September with first-degree felony aggravated sexual assault of a disabled person after being accused of harming a female resident.
“We are grateful that there is extensive and intensive oversight at the centers,” Belile said. “I’m glad things are reported. I think staff needs to be held accountable.”
Dennis Borel, with the Coalition of Texans with Disabilities, believes that some residents will always be too frail or behaviorally challenged to fare well in the community and says that some centers should remain open. But others should close, he said. He believes it’s inevitable.
“It’s going to be a process but there’s no longer any excuses,” he said. “They haven’t proved they could make compliance. They couldn’t prove they’re a popular choice for the consumer. They’re just being protected incorrectly. People with disabilities are the ones who are paying the cost.”
Injuries, neglect decline
State officials have repeatedly said that they never thought fixing the centers would be fast or easy. The settlement agreement, which is hundreds of pages long, was written very broadly and touches on every part of the center operations, Williams said. A large part of the DOJ agreement required the state to overhaul the services they provide, the way they perform them, and the way they measure success.
Parts of the settlement were vague and the independent monitors had to determine whether the state was complying with the spirit of the requirements, Williams said. That made it harder for the state to demonstrate improvement.
Recently, Williams said, the DOJ and state changed the way progress is measured to focus more on individual outcomes instead of processes. Officials hope that will put the centers on a faster track to meeting the federal expectations.
“We focus on quality of life and providing amazing services with dignity and respect,” Williams said.
The centers’ long-standing problem with turnover has also been cited as contributing to the slow pace of change. Some centers lose 39 percent of their direct care staff each year, forcing the facilities to constantly train newcomers.
Reports from the independent monitors show some centers are improving in areas such as restraints, data monitoring and abuse and neglect reporting. Meanwhile, the centers overall have greatly decreased the number of injuries to residents and staff.
From fiscal years 2014 through 2017, reported injuries to residents decreased 25 percent, going from 42,673 to 32,166. Most of the injuries were small, with some requiring minor first aid such as bandages or ice packs. But 298 were considered serious — with injuries such as broken noses caused by other residents — down from 516 in 2014.
“Better training, better oversight and monitoring, better planning for the residents, and improved programming are some of the reasons,” Williams said.
Additionally, confirmed incidents of abuse and neglect have dropped 35 percent since 2010, again outpacing the shrinking population.
‘No middle ground’
Still, detractors say the centers remain an unsafe place for residents. Sen. Juan “Chuy” Hinojosa, (D-McAllen), has tried twice since 2015 to restructure the living center system.
In 2015, Hinojosa filed a bill to shutter Austin State Supported Living Center and consolidate other facilities. But family members of those living in the homes beat back those efforts, convincing legislators that their loved ones would suffer if forced to move out of the centers, and the bill died.
In 2017, Hinojosa filed another bill that would have created a commission to identify by 2018 centers that should be shuttered or consolidated with others. The facilities posed serious health and safety concerns, he said. There was too much abuse and neglect and the aging infrastructure was a problem, with old pipes leaching lead into the drinking water at some centers, he said.
Again, Hinojosa’s efforts failed. After passing in the Senate, the bill was altered and ended up stuck in committee in the House.
Hinojosa says the resistance to consolidation makes no sense. Reducing the number of campuses would cut overall costs, allowing the remaining centers to attract a better, more stable workforce with higher salaries. Residents would be safer, he said.
While he says he understands the concerns of residents’ families, he is also frustrated and thinks relatives are more concerned about being inconvenienced than about doing what is right.
“It’s because they don’t want to make the sacrifice of moving and getting their relatives someplace safer,” he said. “We will always need SSLCs. The question is how many.”
Legislators, meanwhile, are more worried about losing the centers in their districts because people will lose their jobs, he said. Statewide, the centers employ 11,500 people. Hinojosa has two centers in his district: Rio Grande and Corpus Christi.
“I know this is a very emotional, sensitive issue but we need to make make decisions not on emotion but on the health and safety of the residents,” he said.
Sen. Kirk Watson (D-Austin) says he’s torn. He didn’t support either of Hinojosa’s efforts for a variety of reasons, including the fact that he’s not convinced there are enough community resources to ensure everyone is cared for properly, he said.
“This is a very difficult issue in large part because there seems to be no middle ground for the folks who are the most engaged in this issue,” he said.
Texas isn’t the only state that has been forced to contend with the DOJ. States across the country, Georgia and Virginia among them, have been singled out by the Department of Justice for sub-par services for people with disabilities.
But working with DOJ hasn’t always led to the desired results. Georgia — which agreed to relocate residents into community settings through a settlement with the DOJ — has struggled with abuse and neglect in the group homes where people were sent. Few of the relocated residents are living meaningful lives in the community, medical care is hit or miss and group homes often lack enough trained staff, officials have said.
The DOJ did not respond to questions about whether it has encountered any situations like the one at the Texas living centers and, if so, what it did. But if the case of Georgia is any example, DOJ isn’t quick to walk away. The federal agency has been working in that state since 2008.
Texas officials say they believe they’re on the right track and will continue to work with the DOJ closely.
“We are a large state with multiple centers serving thousands of residents, and it takes time to make large scale changes of this nature,” Williams said.
Belile said she doesn’t want Shanna living anywhere but the Austin State Supported Living Center.
“It’s beyond what I imagined for her,” Belile said. “She is so happy.”
Troubles date back 12 years
2005: Amid complaints of civil rights violations the Department of Justice kicked off an investigation into the Lubbock facility.
December 2006: DOJ writes report citing serious instances of abuse, neglect and substandard care at the Lubbock center.
March 2008: DOJ investigates the Denton living center
August 2008: DOJ tells state it is investigating all 13 facilities.
December 2008: DOJ reports massive failing throughout the entire living center system, saying that people are dying amid poor care, abuse and neglect.
June 2009: Texas and the DOJ sign an agreement requiring the state to overhaul the living centers in areas such as medical care, civil rights, dental services and abuse investigations.
May 2014: The state’s Sunset Commission advises Texas legislators to shutter six living centers, citing high costs and poor resident care.
March 2015: Sen. Juan “Chuy” Hinojosa files a bill ordering the closure of Austin State Supported Living Center and the creation of a committee to study the closure of others. The bill fails to pass.
January 2017: Sen. Juan “Chuy” Hinojosa files a bill ordering the creation of a “restructuring commission” to study consolidation of some of the 13 centers. But the effort gets tripped up when — after passing in the House and Senate — the bill is altered and winds up stuck in committee.