http://www.washingtonpost.com/wp-dyn/co ... rrer=email

D.C. Cleansed Group Home Death Reports
Court, Council Didn't See Unfavorable Information

By Karlyn Barker
Washington Post Staff Writer
Saturday, August 5, 2006; A01

The District government has altered reports concerning deaths of mentally retarded residents of the city's group homes, deleting damaging information before the documents were turned over to court officials and others who review the cases.
The deletions, discovered by a federal court monitor, included information that described serious case-management failings; delays in obtaining consent for medical procedures; concerns about health care; concerns about autopsy findings and procedures; and problems getting information needed to complete the death investigations.
One report was changed to remove several sentences critical of a case manager's oversight, including a complaint that he had visited the resident only once in eight years. The case manager still works for the Mental Retardation and Developmental Disabilities Administration, according to the court monitor, Elizabeth Jones.
Jones's interim report about the deletions, filed in U.S. District Court this week, comes at a critical time for the D.C. government. A federal judge is weighing a request to have the troubled agency placed in court receivership, a move that city officials say would derail their efforts to improve operations.
Jones frequently has faulted the city for the care and oversight of roughly 2,000 mentally retarded wards, most of whom live in group homes. In November, she said a pattern of neglect led to four deaths since late 2004, and she warned that other lives were in danger.
In her latest report, Jones says the city also deleted some recommendations from the investigative contractor, the Columbus Organization, that urged the mental retardation agency to change policies or practices to avoid future harm to group home residents, many of whom also have physical disabilities.
"Recommendations for improved health practices were not considered," she writes.
Jones first raised concerns about altered reports in June, after discovering that parts of one death report had been deleted. She then asked that original copies of 19 death investigations be sent to her to compare against copies circulated by the District.
Of those reports, she says in her court filing, eight had significant deletions. The deleted material deprived oversight bodies -- including the court, a fatality review committee and the D.C. Council -- of information they needed to protect and improve services for disabled residents, she says. The information also was withheld from plaintiffs in a long-standing federal lawsuit over the District's care.
D.C. officials said the death reports are edited to ensure quality and to correct typographical and grammar errors -- not to alter any findings.
They said yesterday that changes that appear to be substantive were made when the Incident Management and Investigations Unit, which reviews the reports, was part of the Department of Human Services.
In October, that unit was put under the control of the city's mental retardation administrator, who reports directly to Brenda Donald Walker, the deputy mayor for family issues.
"Any recommendations for changes or improvements to the reports are simply recommendations, and it will be up to Columbus whether to accept or reject the recommendations," said Kathy Sawyer, the mental retardation agency's interim administrator.
The District has agreed to Jones's request that all draft Columbus reports now be sent directly to her.
It was unclear yesterday whether the District will move to discipline whoever made the deletions. Sawyer said she has not initiated any action. Traci Hughes, spokeswoman for the city's attorney general, said that if the employees are still working for the District, steps will be taken to guard against such deletions in the future.
"The District doesn't want employees to be in the habit of providing misleading or wholly inaccurate information," Hughes said.
D.C. Council member Adrian M. Fenty (D-Ward 4), chairman of the Human Services Committee that oversees the mental retardation agency, called on D.C. Inspector General Charles J. Willoughby to investigate the deletions to determine who was responsible.
"It doesn't get any more serious than altering the records of an independent contractor investigating deaths for the city," Fenty said in an interview. "This is willfully keeping information from the court, from the review committee."
A 1999 series in The Washington Post found that none of the 116 deaths in the mental retardation system since 1993 had been investigated. The District subsequently created the fatality review committee and hired the Columbus Organization to investigate deaths and make recommendations aimed at averting future needless fatalities.
In her report, Jones cites deletions that included statements about lost or incomplete case-management records; failure to appoint a legal guardian to make decisions on medical care; questionable medical care or lack of information about health-care problems; and numerous recommendations for ways to address these and other life-threatening problems.
Cathy Costanzo and Sandy Bernstein, who represent plaintiffs in the federal lawsuit and are seeking to have the mental retardation agency placed in court receivership, said critical information never got to the people who could act on it.
"We don't know how many of these reports may have been changed," Costanzo said, noting that the city has declined to give plaintiffs' attorneys copies of the original reports.
"For us, it calls into question the integrity of the process," she said.
© 2006 The Washington Post Company