How troubled residences for disabled New Yorkers operate for years

At Crystal Run Village Inc., a group home for disabled adults in New York’s Hudson Valley, two residents died within a year from the same reason: They choked trying to eat a meal.

The residents, who died in 2018 and 2019 at Crystal Run’s four-bedroom home in the hamlet of Campbell Hall, were supposed to be supervised by staff during mealtime to prevent mishaps. State records show that did not happen. 

The New York Office for People With Developmental Disabilities, the state agency in charge of overseeing group homes, deemed the deaths preventable, citing them as just two of the instances involving poor supervision at facilities operated by Crystal Run, a nonprofit chain of 46 homes in the Hudson Valley and the Catskills.

A month after the second death, the state issued its most serious public warning about poor conditions—an Early Alert letter. It disclosed more troubling events, including “serious incidents involving lapses in nursing oversight.” In all, the state found at least 16 serious mealtime choking incidents. A resident at a different Crystal Run home also died from choking during a meal. The state determined Crystal Run did not have enough workers to help prevent injuries—despite state requirements designed to prevent these kinds of incidents.

An Early Alert letter issued to Crystal Run Village Inc. in 2019 was in place for more than three years.

The 2019 Early Alert letter was lifted this month, not because Crystal Run fixed the troubled operation—but because the homes were acquired by a different nonprofit, the Adapt Community Network.

A review by the NYCity News Service found that 13 of the state’s most-troubled private and public providers—operating from Brooklyn to the Catskills and from Rochester to Syracuse—have been allowed to continue running dozens of homes and programs despite serious unresolved issues. 

The deficiencies include dangerously dilapidated housing, failure to report serious incidents involving patients, poor nursing oversight, accusations of chronic financial mismanagement and failure to take measures to prevent avoidable deaths.

Easterseals New York, with headquarters at 633 Third Ave. in Manhattan, received an Early Alert letter after three of its group homes were placed in “immediate jeopardy.”

One agency, Easterseals New York, had received an Early Alert letter after three of its group homes were placed in “immediate jeopardy,” a status denoting conditions were so poor that residents should be relocated right away. The Early Alert letter did not specifically describe the conditions. As of July 13, Easterseals has also moved off the Early Alert List. It did not reply to requests for comment.

Another operator of private group homes, Community Options New York Inc., received a 2019 Early Alert letter regarding concerns about issues including healthcare oversight and fire safety. 

“The quality of our services is of utmost importance to us. As we work to overcome COVID-related challenges, we are pleased with the progress we have made to address the concerns presented to us by OPWDD and look forward to coming off Early Alert in the near future,” Community Options told the News Service.

In recent months, the state agency has issued more additional Early Alert letters, raising concerns about the financial stability of two private operators. 

In 2020, the state reported more than 2,600 complaints were filed and closed against privately run facilities. State investigators found more than a third were “substantiated” by evidence. 

Close to a decade ago, after a series of scandals and tragedies chronicled by The New York Times, New York reformed the network of state and privately owned group homes where almost 40,000 disabled residents are living. The residences are intended to be settings in which residents can get the support they need while trying to become more independent. Group home residents have disabilities including autism, cerebral palsy, Down syndrome and other neurological disabilities.  

The group homes currently on the Early Alert list have not resolved their problems for an average of almost three years. The longest unresolved case is almost seven years old. 

The Early Alert letter sent to the Paul J. Cooper Center for Human Services in 2015 is one of the longest-standing notifications from the state agency that regulates group homes for disabled New Yorkers. 

“One has to seriously question whether or not [providers on Early Alert] are viable entities, and really whether or not they should be in business,” said Arthur Webb, who became the commissioner in charge of the state office in the 1980s and left the post in 1990.

Webb told the News Service that out of several hundred providers providing services throughout New York, only “a relatively small number” are on Early Alert.

Residents “are particularly vulnerable because there’s less oversight by the Department of Health,” according to Sean Doolan, an attorney who has represented residents and guardians in suits alleging poor conditions in group homes. 

Doolan said he has seen recurring problems, including “inadequate training, less sophistication in the staff, less organized training.” 

”It leads to abuses that I don’t see in nursing homes,” where there is more oversight, he said. 

A History of Issues

Group homes can remain on Early Alert for years because after one deficiency is solved, another problem can arise. 

Once a group home operator has resolved problems, said Denise  DeCarlo, a spokeswoman for the state agency, “it doesn’t automatically come off the list.” The operator must show that it can remain in compliance for a period of time that varies depending on the depth of the problems.

A News Service review of inspection data obtained under New York’s open-records law shows that, despite state regulations, over 82 percent of the more than 100 facilities operated by private companies now on the Early Alert list are not inspected twice per year—further weakening protections designed for some of the state’s most vulnerable residents. 

The state said the pandemic has led to fewer inspections than required. Yet the data shows the shortfall was happening before COVID-19 hit. The state did not offer any explanation when asked by the News Service about the lack of inspections prior to the pandemic.

A 2021 audit by the U.S. Department of Health and Human Services inspector general found critical gaps in oversight at group homes in New York. Serious incidents were not reported properly, putting disabled residents at a great risk of harm and preventing thorough investigations. 

“New York did not ensure that [group homes] fully complied” with federal rules for serious incidents, the inspector general wrote. The state, which did not dispute the findings, said it is working to improve incident reporting.

“The HHS audit found that in a very small number of incidents, providers did not immediately report an incident; that a very small number of providers did not complete their investigation of incidents within the timelines defined by the regulations; and that two providers did not identify trends in their incident reporting,” the state said. “OPWDD enhanced its training and guidance to providers on incident management and reporting.”

Separately, the News Service also found dozens of lawsuits alleging neglect and abuse within the network of the state’s roughly 300 group home operators—including accusations that residents died needlessly, were injured, abused, and sexually and physically assaulted. The News Service analysis checked each of the state’s licensed residential home operators, as of 2021, against state court records. At Crystal Run, earlier instances had already raised questions about safety that predated the 2019 Early Alert letter.

David James Reece, a resident of a Crystal Run home in Spring Valley, a village in suburban Rockland County, required an aide to work at his bedside to make sure he did not fall and get hurt. But Reece did fall. On March 30, 2016, he died from his injuries. He was in his early 50s.

His mother sued Crystal Run and others, alleging Crystal Run was negligent by not providing enough staff, operating poorly and falling short on safety plans. After Reece fell, the family said, the company was slow getting him to a hospital. Three years after his death, the litigation was settled for an undisclosed amount.

Crystal Run representatives did not respond to repeated requests for comment.

On the List for Years

Most of the state’s homes for disabled people are run by private companies—about 30,000 of the nearly 40,000 residents. The rest reside in facilities operated by the state.

Group homes employ staffers who help residents with tasks like cooking, bathing, cleaning and getting to doctor appointments.

The Office for People with Developmental Disabilities, created in 1978, oversees these services and is supposed to inspect every agency and all of its homes at least once a year, along with undertaking other measures to ensure safety. 

If investigators find a home does not meet state standards, the home must come up with a corrective plan. If it is not followed properly, the state can place the operator on the Early Alert List, a designation that often indicates systemic problems. 

Among the oldest Early Alert warnings that remains unresolved is for Paul J. Cooper Center for Human Services, a nonprofit headquartered in Brooklyn that has been on the list since December 2015. 

The center operates several group home facilities. The state found that the agency’s finances were poor, “raising substantial doubt” it could continue to provide services—including hiring sufficient properly trained staff—and questioned whether its board knew the depths of its fiscal plight. 

A month before the center was put on the Early Alert list, a resident at its Gates Avenue home in Bedford-Stuyvesant, Jermaine Graham, who has autism and a mental disorder, fell from a fire escape, broke his ankle and injured a knee. 

In a lawsuit, guardian Lorice Minter alleged that Graham, then 23, was left unsupervised. The center denied wrongdoing and settled the case in 2018 for $197,500. The injury was not among the reasons that led to its Early Alert letter.

The Paul J. Cooper Center for Human Services did not respond to requests for comment.

Fines and a Rare Closing 

Separately, group home operators can be fined.  

In one case, an unnamed resident at home operated by Community Mainstreaming Associates, a nonprofit in Westbury, Long Island, was hospitalized. State records refer to him only as “K.S.” When he was released from the hospital on April 21, 2021, the home was supposed to let him back to live there but it did not. That violated state rules. The state proposed a $10,000 fine and Community Mainstreaming initially requested a hearing. But according to the state, Community Mainstreaming withdrew its hearing request and paid $3,000. Don Williams, a Community Mainstreaming representative, said the organization cannot comment on the case because of a settlement it agreed to.

While the Office for People With Developmental Disabilities can terminate or not renew an agency’s operating certificates at specific locations, only the state attorney general’s office can permanently shutter homes—a rare occurrence that can take years. 

The Evelyn Douglin Center for Serving People in Need, put on Early Alert in 2019 after a long history of financial mismanagement, is no longer providing services for the state system. Additionally, the state put the Federation of Multicultural Programs Inc. of Brooklyn on its Early Alert list in 2011 for “serious concerns related to the nonprofit’s internal controls as well as significant compliance issues” at one home. A second Early Alert was issued a year later.

News accounts reported the state found that the company, running at a deficit, was “not fiscally viable.” Advocates said conditions were so bad that residents sometimes lacked basics such as toilet paper and clean sheets. The state attorney general shuttered the company in 2016. Five years had passed from the issuance of the Early Alert letter to the closing of the Federation of Multicultural Programs.

The state’s own regional division for the New York City area, the Metro Developmental Disabilities State Operations Office, has been on the Early Alert list since 2015. The Metro office received eight warning letters for specific sites, including the “well-publicized situation on Union Avenue in the Bronx”—in which staffers were reported to have physically abused residents—before being added to the Early Alert list. When asked why the office has been on the Early Alert list for so long, the state said only that “multiple environmental and staffing issues over the years have led to delays in implementation of Metro DDSOO’s original management plan.” 

The state said all issues identified in Metro’s Early Alert letter have been addressed, and that it meets with the Metro team every two weeks for further discussions.

Lawsuits Cite Abuse, Neglect 

In addition to the Early Alert list and state fines, state court filings show allegations of other serious concerns. 

Ann Marie Penenpede, who had Down syndrome and other health issues, lived in a United Cerebral Palsy of New York City group home on Paulding Avenue in the Bronx. 

Over a nine months in 2013 and 2014, she was hospitalized 14 times for unspecified reasons at Montefiore Medical Center, according to one lawsuit. She died on June 8, 2014 at age 44.

Her guardian, Rose Penenpede, alleged the hospitalizations were due to abuse and neglect, and sued. United Cerebral Palsy and Montefiore Medical Center denied wrongdoing. 

On May 17, 2019, the case was settled for $525,000. United Cerebral Palsy paid $275,000 and Montefiore Medical Center paid $250,000. (Doolan, who handled the matter, said he couldn’t speak at all about the case, which was discontinued in 2021.)

One woman, an adult who is autistic and intellectually disabled, lived in an Abbott House group home on Rochambeau Avenue in Brooklyn. Her guardian alleged in civil court filings that the woman was raped and impregnated in January 2016 by Thomas Lang Jr., a staff worker. He was sentenced to 12 years in prison in March 2017.

The guardian sued on behalf of the resident, alleging Abbott House should not have allowed Lang to work with disabled individuals because, according to Abbott House documents, he had been accused of neglect in a case involving a group home resident in 2005.

Abbott House has denied any wrongdoing. The case is ongoing. In May 2022, the court subpoenaed the state to produce documents related to a prior investigation into Lang.

Some pending lawsuits for serious incidents involve facilities run by companies on the state’s Early Alert list. 

One suit states that Saul Salcedo, who had developmental disabilities, was among about a half dozen residents  at a group home in Crotona Park in the Bronx who went on a trip to the Camelback Resort in Pennsylvania’s Pocono Mountains in June 2018. Accompanying them were Community Action for Human Services staff, the suit states, adding that the group shopped at The Crossings Premium Outlet mall and ate at a Sonic restaurant for dinner.

In the early morning of June 15, the suit alleges, Salcedo, in his early 50s, was left unsupervised in his hotel room. Camelback security found him dead on the ground below his balcony, with two broken legs, blood coming from his ears.

Salcedo’s guardian, Cruz Maria Pichardo, sued Community Action, alleging  negligence in his death. The case is ongoing. In 2022, Robert Jenkins, associate executive director of Community Action, responded to Pichardo’s claims by stating  that Salcedo did not receive the organization’s services in 2015-18, was not a resident of the Crotona Park home and that the organization did not take its residents to Camelback during the summer of 2018. He said that Community Action was never investigated for Salcedo’s death and that the lawsuit was the first time the nonprofit had learned of the incident. In April 2022, Community Action withdrew a motion for summary judgment seeking dismissal of the suit. 

In March 2021, the state issued an Early Alert letter for Community Action’s Lodovick Avenue group home in the Bronx, citing “significant deficiencies.” Conditions were so bad, the state said, residents had to be relocated immediately. A follow-up check found the home did not take corrective measures.

In addition to the Early Alert notice, Community Action faced a proposed fine of $10,000 for the dangerous conditions at the Bronx home, including the lack of hot water, the lack of a functioning stove, extensive water damage and the presence of soot and mold. 

Community Action, which paid its fine, did not respond to requests for comment.