Florida Takes Action against Home for Disabled with History of Patient Abuse and Neglect

Sunday, June 26, 2016
Carlton Palms Educational Center (photo: AdvoServ)

By Heather Vogell, ProPublica


After years of tepid action, Florida officials are moving to intensify monitoring and remove residents from a sprawling complex for the disabled that has a long history of abuse and neglect.


The state is taking the unusual step of stationing an investigator at the Carlton Palms Educational Center and forming a special team to closely watch over staff and residents, documents obtained by ProPublica show. Residents will eventually be relocated to new homes.


Carlton Palms, on a remote stretch of lakefront northwest of Orlando, houses 202 people with severe developmental or intellectual disabilities and behavior issues – more than a quarter of the state’s residents in group homes for that reason.


ProPublica published an investigation last year into decades of harsh tactics and outright abuse at the facility and others owned by the for-profit company AdvoServ. Carlton Palms’ workers have relied for years on mechanical restraints, such as ankle shackles and a device similar to a full-body straight jacket, that most other providers abandoned long ago. Carlton Palms’ staff used restraints roughly 28,000 times in less than five years, records showed.


The changes at Carlton Palms are part of a new agreement between AdvoServ and Florida officials. Under the deal, Carlton Palms is also banned from accepting new residents – from Florida or anywhere else – unless the state agrees an emergency placement is necessary.


Since our investigation was published in December, the state Department of Children and Families has substantiated two more complaints of mistreatment there – one that resulted in an injury and another related to inadequate supervision of a resident, state records show. The records do not provide further details on the incidents.


Six additional complaints were made this month alone, including one reported the same day late last week that the state and AdvoServ signed the agreement to better monitor residents and, ultimately, remove them. Those are still under investigation.


Carlton Palms’ residents will move into smaller homes closer to their families over the coming months, according to a statement released by the Agency for Persons with Disabilities in response to questions from ProPublica. The state hopes to complete the moves a year before a federal Medicaid deadline in 2019 to end placements in large, institutional-type settings.


“We look forward to working collaboratively with AdvoServ to ensure a smooth transition for its residents into the community,” said agency Director Barbara Palmer in the statement.


AdvoServ officials declined to comment.


It’s possible that AdvoServ will seek the state’s blessing to run some of the new community homes.


“We understand that AdvoServ will remain in Florida,” APD spokeswoman Melanie Etters wrote in an email, adding that the company is planning to operate smaller homes instead of a big campus like Carlton Palms. The Florida facility is by far the company’s largest. Residents will have a chance to choose their new homes, Etters said.


The Carlton Palms facility has faced enormous criticism in recent years after a series of incidents involving abuse by staff and the death of a 14-year-old autistic girl from dehydration after a night in which she was at times strapped to a bed while vomiting repeatedly.


The state disability agency reached settlements with the company each time it filed formal legal complaints against the facility over abuse or neglect. ProPublica’s investigation detailed how AdvoServ has for years hired lobbyists and lawyers to fend off regulation and shape policy in the states where its homes are located. As of late last year, the company cared for roughly 700 people in Florida, New Jersey and Delaware and was expanding into Virginia.


Under the Florida agreement, the state Department of Children and Families investigator stationed at the campus will have access to all areas and video recordings. The state disability agency willform a team to step up monitoring of all restraints, plans for managing behavior issues, medical care, and staffing ratios. Within two months, the state will hire an independent group to take over the monitoring and develop transition plans for each client.


In addition, the agreement requires Carlton Palms administrators to make sure that video recordings are reviewed whenever there is a restraint, an injury to a resident or a complaint to the state abuse hotline. Carlton Palms is also expected to conduct random monitoring of all video to watch for abuse or neglect.


Video at the center has been the subject of scrutiny before. After 14-year-old Paige Lunsford died, AdvoServ officials said hours of footage of the hallway outside her bedroom had been accidentally deleted.


To Learn More:

Florida Cracks Down on Troubled For-profit Facility for the Disabled (by Heather Vogell, ProPublica)

Connecticut Oversight Agencies Failed to Investigate Years of Abuse and Neglect in Group Homes for Disabled (by Joaquin Sapien, ProPublica)

FDA to Ban Electric Shock Devices Used for Decades on Disabled Boston Residents (by Heather Vogell, ProPublica)

Court-Freed Documents Show 13 Deaths at Developmentally Disabled Facilities (by Ken Broder, AllGov California)

3 State Facilities for Developmental Disabled Face Funding Loss after Patients Found in “Immediate Jeopardy” (by Ken Broder, AllGov California)


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