Deaths of people with intellectual disabilities in Pa. went unreported, says federal regulator

Thousands of unreported “critical incidents,” including two deaths and cases of abuse and neglect, were found in an audit of medical claims.

  • Brett Sholtis/Transforming Health

(Harrisburg) — Companies that help Pennsylvanians living with intellectual disabilities failed to report two deaths and thousands of other “critical incidents” in 2015 and 2016, according to an audit by a federal inspector general. The same audit concluded that state officials failed to ensure those companies followed the rules.

Critical incidents involve things like abuse, neglect, an emergency room visit or the death of a developmentally disabled person who receives Medicaid benefits, according to the report by the U.S. Department of Health and Human Services Office of Inspector General. Medicaid rules require such incidents to be reported to the commonwealth within 24 hours, and state law requires suspicious deaths to be referred to police.

In failing to oversee those caretakers, known as home and community-based providers, Pennsylvania was out of compliance with federal Medicaid rules, the OIG says in the report made public Wednesday.

Abuse, neglect and deaths

Home and community based providers received $2 billion in taxpayer funds last year in Pennsylvania, according to the state budget.

Because the state failed to monitor them, state regulators weren’t able to help people who may have been mistreated, said Nicole Freda, regional inspector general for audit services.

“The community based providers did not report thousands of the critical incidents, emergency room visits and hospital stays,” Freda said. “As such, with that information not being available, the state wasn’t able to act on certain things.”

In one example, a man with intellectual disabilities who was in the care of a community based provider was taken to the hospital where he was found to be dehydrated. The next day, the same man returned and was diagnosed with “bedsores and recurrent dislocation of the pelvis.”

Those two hospital visits—never reported to the state—came less than two weeks after a previous critical incident that involved criminal neglect.

In that incident, the man’s mother pushed him in his wheelchair to a park and abandoned him. The man, who is called “the beneficiary” in the report, sat there for five days.

“According to the medical record, law enforcement found the beneficiary covered by a tarp, leaves, and sticks and bound so that the beneficiary could not communicate. Law enforcement brought the beneficiary to the hospital, where he was diagnosed with adult nutritional neglect and assault (criminal neglect),” the report states, adding that the man’s mother had previously tried to drown him by leaving him in a bathtub with the water running.

If the two hospital visits had been reported, someone might have checked in on this man to make sure there was no further mistreatment, Freda said.

Read the report:



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