DDS failed to act on concerns about care in a state-operated group home
We have seen substantial evidence over the years that the Department of Developmental Services’ (DDS) state-operated group homes have better trained and compensated staff on average than staff of corporate provider-run homes.
But problems can still plague state-run facilities if the Department removes resources from them, fails to ensure that staff are properly supervised, or fails to nurture a culture of caring.
If we see evidence of any of those things happening, we think it’s important that DDS investigate immediately in order to prevent the situation from spreading and possibly damaging a vital part of the system of care.
One apparent and hopefully rare example of those problems is alleged to have occurred in a Northeastern Regional Services (NRS) home in Peabody. Jeannine MacKinnon claims the staff there provided such poor care to her son Zachary that she finally had to take him home in January. Zac is 32, autistic and non-verbal.
NRS is a division of DDS that operates group homes in the northeast region of the state.
In this case, DDS doesn’t appear to have made serious efforts to respond to Jeannine’s many concerns over months or even years about serious lapses in care. Departmental officials repeatedly assured her they would look into her concerns, but problems persisted without indications that any solutions were tried or implemented.
Zac MacKinnon
Jeannine said that while Zac was in the group home, NRS officials criticized her as “a combative mother.”
Unfortunately, bringing Zac home hasn’t been a viable solution for Jeannine. Jeannine, who is disabled, said she can’t sustain his care in her home. Zac needs 24-7 care, elopes, and has seizures.
On May 6, we wrote to DDS Commissioner Sarah Peterson, urging her to act quickly to locate a suitable alternative residential location for Zac and to relieve Jeannine of the burden of continuing to try to care for her son on her own. We also requested that DDS investigate the NRS group home system in light of the problems Jeannine has identified in the Peabody residence.
Peterson responded to us a few days later, saying that while she “could not comment or provide specifics related to any individual cases, please know that I have reviewed your email, followed up with the team and will continue to do so.”
In fact, Jeannine said that earlier this month, DDS provided her with two possible alternative residences for Zac. She said she has had a “good conversation” with the corporate provider operating one of those homes.
Bruises and infections
At the NRS group home, Jeannine said, she often found her son “covered in bruises and covered with MRSA infections” and receiving no medical treatment. She sent us photos of those bruises and infections, many of which would be too graphic for us to publish.
Last month, DDS notified Jeannine it was investigating many of her claims, including allegations of a broken rib, bites and scratches, bruising, and skin infections on Zac. DDS also said it would investigate allegations that Zac was regularly assaulted by another resident of the group home and was locked out of his bedroom during the day by the staff so that he couldn’t escape from the other resident.
Another allegation of Jeannine’s was that Zac was forced by the staff to wear a confining bodysuit during that day that was zipped from behind. While the suit was intended to keep Zac from self-injurious behaviors, it was only supposed to be used at night.
While the investigation by the Department of Jeannine’s specific allegations is welcome, it is not clear that it will involve a systematic review of NRS’s management and oversight of its residences.
The alleged problems in the NRS home, which are documented in emails to DDS, are discussed below. We would note that DDS officials did not dispute any of the concerns that Jeannine raised with them.
Attacked and kept from bedroom
Jeannine said that among other problems, Zac had been subject for months to physical assaults by another resident in the NRS home, and that for some reason, the staff wouldn’t allow him to escape from those attacks by going to his bedroom during the day. She said he was forbidden for three years from entering his room until bedtime.
Despite repeated complaints from Jeannine to DDS about the situation, nothing appears to have ever been done about it.
In one email exchange about that problem, Jeannine wrote to an investigator with the Disabled Persons Protection Commission (DPPC) on August 11, 2024, saying, “I don’t want to repeat myself, but the group home called me tonight to say (Zac) was attacked again! The group home staff is short-staffed every weekend leaving my son more at risk.”
Two days later, on August 13, Jeannine contacted her son’s DDS service coordinator, the supervisor of the group home, and a clinical therapist, saying, “My son does not even have access to his bedroom to flee from sick situations.”
That same day, which was a Tuesday, Zac’s DDS service coordinator responded, suggesting scheduling a meeting with Jeannine either for the following week or the week after that. “I am very sorry you don’t feel like we’re helping you with Zac,” the service coordinator wrote, not specifically acknowledging that a problem existed.
A month later, on September 10, Jeannine emailed an occupational therapist at Mass General Hospital, who was involved in her son’s care. “What is going to be done so that Zac can access his bedroom?” she asked. “They know he (the other resident) attacks Zac. For whatever reason they need to be separated.” The occupational therapist responded that Jeannine should contact the DDS ombudsman about the issue.
Photos of bruises and infections
On October 10, 2022, Jeannine sent photos of bruises and skin infections on her son to Bonnie Hungler, DDS Metro North area director. Regarding the bruises on Zac’s arm, Jeannine said she had been told Zac had fallen off a couch the previous Saturday, but she didn’t believe the explanation.
Two days later, Hungler responded, saying, “I am very sorry to see the significant bruising.” She said the injuries had been reported to the DPPC and that she intended to speak with the NRS director, ”to discuss and see what his team has learned after speaking with staff on shift.“
Hungler also said she expected that DDS would probably investigate the incident. The DPPC did refer the investigation to DDS, which concluded in a 1½ page report that abuse was unsubstantiated. Only five people were interviewed in the investigation, in addition to Jeannine herself.
In August 2024, almost two years later, Jeannine was still sending photos of her son’s bruises and infections to DDS and other officials, and apparently receiving little if any response, and no solutions.
On August 6, 2024, Jeannine wrote to an administrator at Jewish Family and Children’s Service. “I am sharing pictures of what I can only call abuse and neglect on my son in the care of the state run group home he is in,” Jeannine wrote. In response, the JFCaS administrator wrote that the photos “are concerning,” and stated that the organization had reported the matter to the DPPC.
Forced to wear bodysuit
As noted, Jeannine maintains that the group home staff began forcing her son, early after he moved in, to wear a bodysuit that zipped up in the back to prevent potentially self-injurious behaviors. But while the suit had been approved for use at night, it was not supposed to be put on him during the day.
Yet, the group home staff was putting the suit on him at all times, Jeannine said, and her son began injuring himself attempting to get it off. In October 2022, after unsuccessfully appealing to NRS, Jeannine wrote to then DDS Commissioner Jane Ryder and sent her a photo of a wound on her son’s back. She said a buckle on the bodysuit had caused the laceration on Zac’s back.
In her message to Ryder, Jeannine discussed other injuries as well. “My son is non-verbal and has no way of protecting himself,” she wrote. “He has no way to take it (the suit) off so he wets or soils himself and sits in his own urine eating away at his skin while he waits for someone to take care of him.”
The following day, Ryder responded to Jeannine, saying that, “I feel horrible about everything you and Zac have been through. My staff will continue to ensure that we are doing everything to make sure Zac is safe.”
Ryder added that, “NRS has acknowledged the failure to notify you in a timely manner (about injuries) and this has been addressed with staff. Your service coordinator will be visiting the home and will be continuing to monitor.“ But Jeannine said no improvements in her son’s care resulted from her contact with Ryder.
Staff wouldn’t use communication device to prevent toileting accidents
In August of last year, Jeannine emailed Zac’s service coordinator and NRS officials, saying that the group home manager was not allowing Zac to use his IPad to communicate his need to use the toilet. “He (Zac) has no way to tell anyone (of his needs) without the constant use and consistency of his IPad,” Jeannine wrote. She added that she witnessed staff allow Zac to urinate in his pants during a medical appointment rather than providing him with his IPad, which was in his backpack.
Approximately 10 months before that, in October 2023, Jeannine had emailed a previous service coordinator, stating that while being driven by staff to a medical appointment which Jeannine attended, Zac had had a urinary accident. She took him into the bathroom at the medical center to change his clothing, but discovered that the staff had packed previously soiled clothing in his backpack. “This entire day has started off really bad, when it could have gone a lot smoother if things were done properly,” she wrote.
No day program and no residential alternatives
Throughout Zac’s three-year stay at the NRS group home, he was not provided with a day program. In November 2, 2023, James Bath, director of family medicine at the Mass. General Hospital Lurie Center, wrote a letter stating that Zac needed a day program in order to provide him with “regular activity, structure, and social interaction,” which he was not getting in the group home.
Dr. Bath noted that the lack of meaningful activities and social interaction in the group home was directly causing symptoms of mild depression in Zac.
Until now, Jeannine maintains, DDS had failed to provide her with a residential alternative for Zac even though she had asked many times that one be found for him.
Thorough investigation needed
It’s not often that we would concur with an assessment that a state-operated group home is not a suitable residential setting due to substandard care. We hope Commissioner Peterson takes this matter seriously and investigates this situation thoroughly.
DDS’s state-operated group home network is an integral piece of the total continuum of care for people with intellectual and developmental disabilities. The network has a reputation for providing excellent care from staff who are well trained and are motivated and conscientious.
If things are starting to slip in any portion of that network, DDS needs to act quickly to determine the cause of the problems and make the necessary corrections.
COFAR blog 
Because of our consistent advice to have folks who are not being well cared for in provider homes to move into state operated care, this is a particularly distressing story. Zac’s mother did everything right. She called all the right people (including both DDS commissioners) who were empathetic and agreed that something was clearly wrong. But yet nothing changed! Hopefully he is on a better path now, but it took his mother pulling him out of the house to actually get attention.
Caring and accountability must be the two main concepts in DDS – especially in residential care, which is so crucial to Zac and to families in need of these services. Zac is non verbal. He cannot speak for himself! And the only communication tool that works for him was apparently not consistently allowed (his iPad). He had his own instinctive solution – to go to his room – but this too was not allowed! This staff needs oversight and training. And we worry about other residents who do not have a mother who is able to watch as closely as Zac’s does. She is not a combative mother, she is a good and diligent mother! So disappointed and angry to read this story about Zac. I hope he finds a better placement, and I hope that DDS uses this story as a wake up call to see what is going on in this NRS residence.
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I’m going to ask the obvious questions:
Has the quality of staffing changed in this location? Is the state now hiring cheaper, untrained (or barely trained) labor?
Has this facility switched to private or non-profit status?
These are the things I am curious about.
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I think the answer to both of your questions is no, the staffing hasn’t changed, and no, the group home is still run by NRS, a division of DDS.
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nonverbal clients need cameras in group homes. period.
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It’s obvious that HCBS group home services are not working for Zac and Jeannine. I hope that Jeannine will consider joining the Saving Wrentham and Hogan Alliance. We believe that the entire system will improve with choice and competition. Please consider emailing us at savingwrenthamhogan@yahoo.com.
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My comment
Nonverbal people must have in-house cameras to stay safe.
Wilhelmina Murray
774-270-1523
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interesting banks have cameras on every money machine, no matter who the staff are, but we won’t protect our most vulnerable people with cameras in group homes
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Every individual should be safe in their home. Every individual has the right to live free of abuse, neglect and exploitation. That includes, but is certainly not limited to, abuse from other household members. DDS should know that? They should also be familiar with the DD Bill of rights, Medicaid requirements for free of abuse, neglect and exploitation, and Social Security requirements for the same, as well as 1150B and title 42.
The failures of DDS 2018 report from the Inspector General report on Mass, CT and RI resulted in Congress issuing an order that DDS shall not be investigating allegations of abuse. Massachusetts seems to ignore that. Additionally, DDS should be very aware, as should DPPC, that on immediate of complaint received, triage to prevent further abuse, neglect and exploitation shall be done, then an investigation starts. DPPC along with local and state police should have responded and triaged the individual. Not forward the complaint to DDS. It’s negligent.
Not finding a day program after a doctor issued an order for one three years ago is blatant neglect to provide support and services to the individual who clearly needs support and services.
And most importantly, his room is HIS. That is supposed to be his home, his safe place. to withhold access to him, as well is give him a safe place to escape abuse is abuse in itself. It violates the community rule, and in itself is abuse.
Are there federal required staffing limits? If not, it’s about time they start implementing them. There is always the excuse of short staffed. Upper management should be filling in why they are looking and training for adequate staff.. it seems that shortages of staffing adds to substandard care.
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Thank you for continuing to shine a light on what is happening inside our state’s care system. I want to add my voice to this critical conversation.
My ward, a vulnerable adult with intellectual disabilities, was in the care and custody of Northeastern Regional Services (NRS) for 8 months. During that time, she suffered neglect, mistreatment, and emotional harm. I submitted two reports to the Disabled Persons Protection Commission (DPPC) detailing serious concerns, but both were screened out, which only seemed to embolden NRS staff and deepen the pattern of abuse.
Instead of addressing the issues, NRS leadership turned against me, labeling me a “combative parent.” Executive Director Scott Kluge was irrationally hostile during interactions and consistently refused to investigate or acknowledge our reports. He repeatedly pressured us to “seek self-direction,” essentially trying to offload responsibility rather than repair the toxic culture within his own agency.
There is a deep, systemic problem at NRS which stretches from executive leadership to direct care staff. This is not a rare case. This is a pattern. The lack of oversight, the culture of defensiveness, and the refusal to listen to families are putting lives at risk.
It is time to raise public awareness and demand that NRS be thoroughly and independently investigated. Vulnerable individuals deserve safety, dignity, and care. Families should not be vilified for advocating for their loved ones. They need to be heard.
The system must do better. And it starts with listening to the very people it was created to serve.
I agree that there should be cameras in group homes – I requested this and Scott Kluge angrily refused, stating that his staff has rights.
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Thank you for continuing to shine a light on what is happening inside our state’s care system. I want to add my voice to this critical conversation.
My ward, a vulnerable adult with intellectual disabilities, was in the care and custody of Northeastern Regional Services (NRS) for 8 months. During that time, she suffered neglect, mistreatment, and emotional harm. I submitted two reports to the Disabled Persons Protection Commission (DPPC) detailing serious concerns, but both were screened out, which only seemed to embolden NRS staff and deepen the pattern of abuse.
Instead of addressing the issues, NRS leadership turned against me, labeling me a “combative parent.” Executive Director Scott Kluge was irrationally hostile during interactions and consistently refused to investigate or acknowledge our reports. He repeatedly pressured us to “seek self-direction,” essentially trying to offload responsibility rather than repair the toxic culture within his own agency.
There is a deep, systemic problem at NRS which stretches from executive leadership to direct care staff. This is not a rare case. This is a pattern. The lack of oversight, the culture of defensiveness, and the refusal to listen to families are putting lives at risk.
It is time to raise public awareness and demand that NRS be thoroughly and independently investigated. Vulnerable individuals deserve safety, dignity, and care. Families should not be vilified for advocating for their loved ones. They need to be heard.
The system must do better. And it starts with listening to the very people it was created to serve.
I agree that there should be cameras in group homes – I requested this and Scott Kluge angrily refused, stating that his staff has rights.
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DPPC was called 3x on my son at this provider. twice screened out. There is a recent issue still under investigation. DPPC told me they have suggested cameras but NRS multiple time refuses claiming its a licensing issue. I have tried to get cameras in my sons room due to multiple unexplained injuries serious to he had 2 icu stays in 5 months . Their Human rights has ignored my request for due process. Somethings not right. What needs to happen? Part of the problem is things happen and staff doesn’t document it, and because of this it never happened so DPPC doesn’t find anything and there are alot of “I don’t knows” and I lose sleep over it. I am unable to bring him home, and have guilt over that as well
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not that this helps with abuse, but there is a wearable watch companion to the IPAD for speech. That may help solve one problem if there isn’t any sensory integration issues that would prevent wearing the companion for when the IPAD is out of reach.
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