A joint investigation of the New England Center for Investigative Reporting and WBUR
With light streaming in through windows overlooking a glittering Dorchester Bay, hundreds of Massachusetts mental-health workers and advocates gathered earlier this month in a cavernous room at the John F. Kennedy Library in Boston to honor a slain colleague – and looked for reassurance from state and industry leaders they’ll be kept safe on the job.
Stephanie Moulton was 25 and working alone at a Revere group home when she was slain in January, 2011, allegedly by a client with a history of violence. To the sounds of Sarah McLachlan singing “Angel,” Moulton’s short life flashed by in family photos on a wide white screen: a baby girl smiling for the camera in her red, white and blue pinafore; a toddler vamping for an audience with a toy microphone; a satin-clad flower girl carrying a wedding basket; a gap-toothed schoolgirl; an excited teen with her prom date; a beaming graduate armed with her diploma.
The crowd gave a standing ovation to Moulton’s mother, Kim Flynn, after she vowed to continue her fight to protect mental health workers like her daughter. Flynn and her family helped convince the Legislature to carve out $100,000 to hold the annual “Stephanie Moulton Safety Symposium” and are pushing for passage of a new state law named for her daughter that would give all workers a “panic button” to summon emergency help.
“She was just awesome,” Flynn told the hushed group, remembering her daughter. “I just want a real positive thing to come out of this.”
But nearly two years after Moulton’s death, unease remains rooted in the minds of not only mental-health workers, but the clients they serve and their families. A joint investigation by the New England Center for Investigative Reporting and WBUR disclosed yesterday that a 24-year-old aspiring singer with various mental illnesses, Malissie Holloway, hung herself in a Somerville group home in June; her body was not discovered by workers for more than two days, a Department of Mental Health investigative report shows.
At the core of the problem is the state’s policy to move mental-health patients out of state-run institutions and into group homes and other facilities, such as eventually their own apartments, often run by independent vendors contracted by the state’s sprawling Department of Mental Health. Although many mental-health practitioners contend that this results in better care for patients, the shortcomings of the policy – especially as it affects the care-providers who work directly with the patients -- have been highlighted in two separate and critical reports, one commissioned by the Department of Mental Health itself after Moulton’s murder, the other released in September by the Disability Law Center, which advocates for the mentally ill.
An independent investigation by the New England Center for Investigative Reporting and WBUR-FM validated the substance of those task-force reports.
The investigation entailed interviews with dozens of direct-care workers; patients and their families; lawyers; mental-health advocates; vendors; state officials; an analysis of thousands of calls for police assistance, and a review of more than 1,000 pages of court documents and records released by the federal Occupational Safety and Health Administration (OSHA).
It found widespread concerns by health-care workers about workplace security in spite of more optimistic reports from the mental health vendors and DMH Commissioner Marcia Fowler. It also found that even when safety complaints were brought to the attention of federal regulators, action was not always taken, in part because of a lack of a workplace violence standards and jurisdictional issues.
Caught in the middle is a dedicated but often wary work force, people who spend days and nights with mentally-ill clients, often with minimal security beyond calling local police for help.
The home where Stephanie Moulton died a brutal death, operated by North Suffolk Mental Health Association, has come in for particular scrutiny – much to the frustration of its administrators and staff.
“They grieve her death and it has affected the very fabric of our organization because she was one of ours,” said Jackie Moore, North Suffolk’s executive director. The NECIR and WBUR investigation found, however, that federal regulators concluded that North Suffolk’s “entire operation” was unsafe at the time of Moulton’s murder. OSHA, which cited North Suffolk following Moulton’s death, and the U.S. Department of Labor are prepared to show a “number of incidents of violence or threatened violence at locations operated by North Suffolk,” DOL Senior Trial Attorney James Glickman argues in court records for the case, now pending at the OSHA Review Commission.
OSHA and oversight
The largest component of state mental health services in Massachusetts is known as “Community Based Flexible Supports” or CBFS, which serve nearly 14,000 individuals. Other than North Suffolk, OSHA has cited only one other CBFS vendor for workplace safety violations since 2007, federal records show. In order to intervene in Massachusetts, OSHA had to resort to the “general duty clause” in the law, which broadly requires employers to keep their sites free of “hazards.”
North Suffolk’s lawyers are firing back at OSHA and the DOL, contending that the citation OSHA issued was vague, overly broad and unfair to the mentally ill by describing patients as a “preventable recognized hazard.”
“It’s stigmatizing. It is everybody and we serve babies, children as young as one-month old,” said Moore, North Suffolk’s executive director. “That is saying our entire population is a hazard and that doesn’t seem right.”
Moore also said she thinks regulators are categorizing some incidents as assaults that are accidental in nature, such as a client letting a door slam shut.
OSHA dismissed another North Suffolk worker’s complaint about inadequate staffing last August, saying it lacked jurisdiction. The August, 2011 complaint from a worker, whose name was redacted, said North Suffolk “has made severe cuts in staffing, training and behavioral support services, resulting in violence, health and safety violations for both the clients and the staff.”
The worker said supervisors failed to act on repeated complaints, which included failing to update a client-behavior plan, despite the client’s continued aggressive behavior. Client plans are required to be updated annually. The complaint also said North Suffolk management ignored aggressive client behavior, backdated behavior plans before an audit to cover up the fact they were out-of-date, and relied on untrained, inexperienced “relief” workers to cover shifts. Staff was sleeping through shifts, excessively using sick time and failing to make “steady care calls,” the complaint said.
The worker described a workplace where patients had poured hot coffee on staff, pulled another worker’s glasses off, pinched them, and pulled their hair. One patient was said to have smeared menstrual blood on her hands and then touched door knobs and railings, or when upset, purposely urinated or smeared her feces.
Yet OSHA closed the complaint without action on Aug. 31, 2011 following a letter from Moore who said that the issues were investigated internally and it was “determined that no such hazards exist.”
OSHA officials did not respond to requests for comment on the closure.
A longtime North Suffolk employee defends its safety precautions.
Jonathan Alpert, who is blind, has worked for North Suffolk for more than six years, currently doing group counseling with adults with severe mental illness. He said North Suffolk has installed panic buttons and video cameras for the staff in the Revere group home he worked in and workers are required to take safety training every three years.
“I always feel safe there,” Alpert said.
Medication runs and Alternatives Unlimited Inc.
A recurring complaint from workers interviewed by NECIR and WBUR for this report was a job requirement that they deliver medications to clients living on their own in high-crime areas, an issue also noted with concern by the task force in its report.
“I need a job but I need to live more,” said one frightened counselor who quit her job last summer at a group home south of Boston after her complaints to supervisors about the solo medication runs prompted no action. “I’m not ready to die for $10 an hour.”
“You go out into the community. This is done on a regular route, the same time. In my opinion, it’s a danger to the person going out,” said the 50-year-old single mother. “You don’t know who is watching you . . . and you’re carrying drugs. And everybody knows it.”
The woman, who asked that she not be identified, said she was too scared to continue working despite her passion for assisting the mentally ill.
A similar complaint made by workers at Alternatives Unlimited Inc., last year resulted in no action by federal regulators, records show. Alternatives provides residential services to roughly 2,400 people with psychiatric problems in Western Massachusetts. Workers had also complained about being threatened by a knife-wielding client while driving in an Alternatives’ van, records show.
Since 2006, Alternatives workers have been injured dozens of times on the job, including being bitten by a client trying to steal coffee, being hit in the face with a bowl a client pitched, and being scratched by a client’s dogs while delivering medications to the person’s apartment, the records show. In 2011, a client tried to gouge out a counselor’s eyes, requiring the worker to seek medical treatment, the records show.
But in its first inspection of Alternative’s Whitinsville facility last year, OSHA found the vendor had an above-average, written health-and-safety plan in place that was communicated to workers; it did not issue a violation.
Alternatives Chief Executive Officer Dennis H. Rice said in a written statement the complaints were part of a failed effort to unionize workers and said safety is a top priority.
“We do our job well and the result is we are given some of the state’s most challenging individuals to support,” Rice’s statement said.
In February, OSHA did cite Alternatives for failing to immediately dispose of lancets, syringes and needles after use, potentially exposing workers and clients to HIV and hepatitis. There were six injuries to workers and clients from needle pricks between 2009 and 2011, OSHA records show.
Alternatives is paying a $2125 fine for the violations, according to a copy of the Feb. 8, 2012 settlement agreement. Alternatives was also cited for failing to maintain a required log of “sharps” incidents from 2006 through 2011, for which it was also fined $2550. That penalty was dropped as part of the settlement agreement, records show.
“One sharps injury is one too many. Yet the context is important: Alternatives’ staff administers thousands of glucose monitoring tests and medication injections annually,” Rice said in his statement.
Department of Mental Health Commissioner Marcia Fowler said the agency has made significant strides in the past year to address safety concerns for workers and clients by acting on the task force recommendations, including ramping up safety training, obtaining $100,000 from the Legislature to hold the annual safety symposium and securing $10 million in funding for CBFS providers.
“We will prioritize services that support people in the community, people in their living environments that maintain safety and security,” Fowler said.
But for workers on the front lines, even those who feel the vendors are doing the best they can, there is still cause for concern.
“You have vendors out there who are running programs with half the staff; the vendor has to do it to stay in business,” said one advocate who works in the system but would not allow her name to be published. “There is an incentive for the vendor to put the client in far less supervised settings. I think it is just a matter of time before there is another tragedy.”
The thought chills Kim Flynn as she battles to honor her daughter’s name.
“She sacrificed her life to make positive changes,” Flynn said. “Everywhere you go, every song you hear, every word that’s said . . . you don’t not think about her. Everything reminds you.’’
The New England Center for Investigative Reporting (www.necir.org) is a non-profit investigative newsroom based at Boston University. Jillian Sandler and Sydney Lupkin of NECIR contributed to this report.