In a closet in his dorm room at Richmond State School, Trevor Falk keeps his one nice suit.
The 24-year-old with Down syndrome wears it on Sundays when he attends church services, and he usually makes the five-minute walk to the school's chapel with the two roommates he calls friends.
During weekdays, Trevor is often alone, free to walk the 240-acre campus delivering mail to other residents. He also works in the administration building answering phones, and with paychecks from the two jobs, he's saved a little more than $1,500, according to his mother, Linda Falk.
It's a big leap for Trevor, who was sometimes restrained with a straitjacket when he first came to the school two and a half years ago.
One afternoon in May, Trevor left his dorm room planning to pick up mail for other residents, but saw his mother outside. She was visiting that day, but Trevor hadn't known when she was coming. The two saw each other and embraced.
"What do you want to do today Trev?" Linda Falk asked.
Without missing a beat, he said, "Go to a group home."
Trevor's answer surprised his mother, but then again, maybe it shouldn't have. Several times a year, a horde of representatives from the hundreds of privately owned group homes in Harris and Fort Bend counties visit the state school to promote their private facilities. Patients at Richmond often wear T-shirts and carry tote bags displaying names of group homes, picked up with other free swag at the promo fairs.
The effort pays off. The population of disabled residents in group homes in Texas has grown to about 14,000, and the industry generates about $896 million in revenue from state funds alone, according to the state's figures from 2008.
Private providers are paid about $4,700 per month per client, so for a place like Four J's Community Living Centers, which serves about 80 clients near Sharpstown Mall, that's $366,600 per month. Most providers also own residential homes, and to pay for room and board, clients sign over their Social Security checks.
As the private system has grown, the knock against Richmond and the state's other 12 mental facilities has become easier to make.
In 2005, the United States Department of Justice visited Lubbock State School and during the 18 months that followed, even with federal investigators in and out of the school, 17 patients died while employees attempted to cover up some of the deaths.
A couple of years later, the Justice Department investigated Denton State School, involved in its own scandal after Kevin Miller, a state school employee, admitted to almost beating to death a mentally retarded man. Later, Miller told investigators about rampant neglect and drug use by the school's staff.
And in March of this year, a cell phone was found at the Corpus Christi state school containing video of disabled residents in fights — nationally publicized as "fight club" fights — apparently set up by school employees. In the worst cases, the employees kicked and slapped already-injured patients.
More abuse at Corpus Christi has come out since the videos were released. According to The Dallas Morning News, school records show a worker falling asleep while driving patients, causing the van to roll over; an employee whipping a patient in the face with a belt; a staff member restraining a patient by flipping over his wheelchair; and an employee using a walking cane to beat a patient.
In May, a 15-year-old girl hung herself with her shoelaces at San Angelo State School, and according to an article in the San Antonio Express-News, the girl's mother had previously received more than a dozen letters in one year from the Department of Aging and Disability Services about complaints her daughter made alleging abuse from the school's staff. Only one case of neglect was confirmed and an employee was fired.
Richmond State School has not been without incidents itself.
State documents show at least one confirmed case of neglect during 2008. It happened after a staff member was watching TV instead of his patient, who fell down getting out of bed. Despite finding him with blood running from his nose, the employee did nothing. A checkup the following morning revealed the patient had fractured his face in three places.
Almost all other reports were marked "unsubstantiated," ranging from allegations that employees dispensed the wrong medications, to urine and fecal matter on furniture, to clients having sex in front of buildings.
Those complaints, according to investigators, didn't warrant citations.
A Justice Department report released in December 2008 cited 36 deficiencies at Richmond, including "failure to ensure clients' rights were protected, including the right to be free from abuse, neglect and mistreatment" and "failure to show that all allegations of abuse, neglect, or mistreatment were thoroughly investigated."
There were cases of neglect at every state school in Texas, according to the report, and before the state legislature kicked off its session this spring, Governor Rick Perry declared protection of state school residents a "legislative emergency."
At the same time, equal attention wasn't being paid to the private community-based homes in Texas. And actually these homes operate under far less stringent state regulations than state institutions do.
Unlike state schools, private providers outsource any additional medical or therapeutic services. Group home residents receive what a Medicaid case worker allows, or only what Medicaid will pay.
More than half of the Texans with the most severe mental retardation are served in state schools, and "that's exactly the way you'd think it'd be," says Jim Miller, who has a 39-year-old son in Denton State School.
"That's the population [private providers] know they can't profit from," he says.
Still, legislators and advocate groups for the mentally retarded and physically disabled push hard to get state school residents into private homes, to integrate them into "the community," and Trevor is exactly the kind of patient that private homes covet. He's young, independent and healthy.
His parents, however, have seen how Trevor fared in group homes and private care.
Before he moved to Richmond, Trevor was kicked out of 13 different private facilities in four months, getting drugged, robbed and beaten along the way.
"He has the mental capacity of a fourth grader, but he's not stupid," says Trevor's father, David Falk. "He figured out that if he didn't like a place, all he had to do was tear it up and they'd send him to the streets."
Trevor escaped once from Richmond State School.
At dusk one evening, he slipped out of his room and strolled across the school's sleepy if not serene campus. He walked past the main gate and security booth and crossed a wide open field, crawling underneath a wooden fence that borders the school's southern edge.
He made it about a half mile down the road before a couple of state school employees caught up with him in a van and took him back home.
"There's so many staff people in and out that he never gets very far," says Linda Falk. "Staff will see him, whether they're on the clock or off the clock, and pick him up and bring him home. Or they realize he's gone before he's out the gate."
The superintendent of Richmond, Al Barrera, gushes about the residents' freedom to roam the school's campus. There isn't a main building and almost all the structures are single-story, nearly hidden underneath the clusters of trees that dominate the campus. Residents walking around the sprawling green spaces and small, 1960s-era brick buildings give Richmond the slight feel of a private university during a summer semester.
"I have seen so much change in the last ten years," says Barrera, who took over the school in 2000. He's driving a golf cart through the campus, directing a tour, and his first stop is a covered arena used for therapeutic horseback riding. "It's not like the old days where you come to a state school and stay here for a lifetime."
The place is hardly a school anymore. When it opened in 1968 — nine of Texas's 13 state schools opened in the 1960s and 1970s — most of the residents were young teenagers. State legislators in 2001 stopped the enrollment of children younger than 22 without a court order, and the minimum age has since risen to 25, according to Cecilia Fedorov, a spokeswoman for the Department of Disabilities and Aging, the agency that regulates state schools and group homes.
The average age at Richmond today is 46, with no resident younger than 17, and statewide, only 3 percent of the 4,600 state-school residents are younger than that age.
Today, more of the mentally retarded never go to an institution, or are only there for a while before moving on.
"In the '60s and '70s, there were no community services," Barrera says. "Today's parents are being given more options for services, with the state school being the last option of resource."
The school's newest housing "cottages" were built in 2001. The women who live in one of the cottages are all older than 30, but the rooms could belong to young girls. Pink bedding is a favorite, with pictures of movie stars and unicorns plastered on the walls.
The population at Richmond, like other state schools, has steadily dwindled in the last 30 years, with enrollment peaking in 1980 at about 1,400 residents. Twenty years later there were about 700 residents at the school, and today, the population has dropped to around 480.
"I think that speaks well because we were able to place people in the community," says Barrera, who parks the golf cart in front of a building that houses the school's "Forever Young" program, for residents older than 50. "When there's money in the community, our enrollment is down."
Fedorov adds, "I don't think it will ever go back the other way."
It costs the state about $125,000 per year to care for each resident in a state school, and Texas spends about half that on each person in a private home.
"There have always been people who want to close state schools, and there's one factor that plays into it in a very significant way, and that's the cost factor," says Charles Ferguson, who has a 53-year-old daughter in Denton State School. "But it's a pretty good place. My daughter lives on a campus, in a community. If she were living in a group home, she wouldn't be able to get out of that house."
If the state schools closed, he says, "it'd be a tragedy that few people understand."
Advocacy, Inc. and The Arc of Texas, advocacy groups for the mentally retarded and physically disabled, have led the opposition to state schools in Texas.
In an op-ed piece published by the Houston Chronicle during the summer of 2007, Mary Faithful, executive editor of Advocacy, Inc., wrote, "There are nearly 5,000 Texans locked away in these state institutions...They have few opportunities to see — or be seen by — the outside world. Most people don't even know they exist."
Faithful continued, "[State school residents] are not content to be parked in front of a television or jigsaw puzzle for hours a day; they think they can do more than tear paper into little pieces for a few cents of 'earnings' each week."
The Arc of Texas and Advocacy, Inc. have filed lawsuit after lawsuit against the state on behalf of people who don't get enough funding for the alternative to state schools: community-based services. In 2006, Texas settled a lawsuit filed by the two groups for seven plaintiffs who were waiting for Medicaid waivers for private care. The agreement called for, among other things, increased state funding of community services until at least 2011 and a reduction of state school populations each year.
Another Advocacy, Inc. lawsuit lost by the state was filed in 2006 on behalf of David Robbins, a cerebral palsy patient whom the state tried to move to Richmond State School after Robbins's privatized funding expired.
"I find it very heartless on the part of the state that they've told the families that it is all or nothing, it's an institution or nothing," Steve Elliot, a lawyer for Advocacy, Inc., told the Houston Press in 2008.
After the Robbins victory, Elliot filed about a dozen more lawsuits for patients in similar situations.
The pressure hasn't let up. Representatives from The Arc of Texas pressed state legislators in April to issue a moratorium on all state school admissions until the schools "could demonstrate the ability to keep residents safe and free from abuse, neglect and exploitation."
During the legislative session this spring, the group also "advocated for a responsible reform of the entire long-term services and support system," says Dawn Choate, a spokeswoman for The Arc of Texas.
She referenced a 90-page report released in late 2008 that outlined recommendations that included reducing the number of people in state schools, expanding home-based services as the primary provider and strengthening the community-service infrastructure.
"There's a complete imbalance between funding streams for institutions and community services," Choate says. Texas currently ranks 50th in spending for community services and 26th for state schools.
But other states have already shut down institutions, and doing so hasn't always worked out that well for their former residents.
In March 2002, for example, New York officials closed Seaport Manor, a home for about 300 mentally ill adults, after The New York Times published an article that said the state's homes had "devolved into places of misery and neglect..." The newspaper's investigation, which covered a six-year period, revealed 946 deaths out of 5,000 New York state school residents.
After the closing, state officials "pledged to do all they could to protect the safety and well-being of its [residents]," making sure the community placements were adequate. The Times found that former residents were discharged to homeless shelters and private homes that the state had already cited for patients wearing urine-soaked clothes, being threatened, given the wrong medication, and living in roach- and gnat-infested rooms.
"I feel very constrained," the New York health commissioner told the newspaper. "Where do I put them?"
In Virginia, about the time the Justice Department released its report on Texas schools, Governor Timothy Kaine proposed closing his state's Southeastern Virginia Training Center, home to about 175 mentally disabled residents.
Family members of the center's residents are fighting the closing, because even after Virginia legislators committed $40 million more to community services, options were sparse in private homes. Some families were forced to send disabled relatives hundreds of miles away after high real estate prices caused nearby group homes to close, according to an article in The Washington Post.
In Texas, state schools serve a large population, but pressure from the advocacy groups and litigation have left few people to fight for the state-run institutions, even the people that run them.
"If my son stayed in a group home, he would be 'in the community' only because he was technically in a group home," says Miller, who has the 39-year-old son at Denton. "He wouldn't be integrated in the community. He wouldn't be able to get out and walk across campus like the state school." Miller enrolled his son at the now-defunct Fort Worth State School when the boy was ten, after Miller found him attempting to drink a bottle of Lysol cleaner.
"We already had to keep chains on the refrigerator," Miller says. "After we got over the trauma of what we did to our son — putting him in the school — we realized it wasn't to him, but for him."
Miller visits Denton weekly to see his son, who has a job in the school's workshop assembling packages of boat propellers. Miller can't go to his son's job because his son will lose focus, but Miller has watched video of him working.
"I can say he's alive today because of the quality of care at the state school," Miller says.
The push to move residents from state schools to community services motivated Miller to get information on abuse or neglect in the private homes, thinking his son might eventually end up in one. Even though the same agency — the Department of Aging and Disability Services — monitors state schools and private homes, the disparity between standards was shocking to Miller.
For instance, a division of DADS creates specific rules on how to care for patients, according to Fedorov. A separate agency, the Department of Family Protective Services, investigates reports of violations of those rules at the state schools and has a zero-tolerance policy for any confirmed cases of abuse.
"Every single instance of abuse or neglect, no matter how small or unlikely, has to be reported," Fedorov says.
A different division of DADS oversees the private homes. Providers are required to report any injury to the agency, Fedorov says, but if a complaint is made, even if it involves abuse, investigators can only check if the homes are complying with state and federal regulations. For instance, if an allegation is made that a staff member hit a resident, state investigators can check to see if a background check was done, if the employee is licensed and if the group home has written policies to investigate complaints. The state can't question the residents or the home's employees or initiate criminal proceedings.
"Investigators will be sent out, for example, to make sure there are bars on the walls for residents to hold onto, or that the hallways are wide enough, or things of that nature," Fedorov says.
Even Choate, the Arc of Texas spokeswoman, acknowledges the lack of oversight in community services is a problem.
"They're not being properly monitored, so we definitely want to take that regulation into consideration," Choate says, but, she adds, "The biggest problem with community services is that there aren't enough."
The minimal regulation at private homes is appalling to state school supporters like Miller, but the more stringent reporting standards and zero-tolerance policies at the schools haven't stopped the horrific cases of abuse there, as evidenced by the Justice Department report.
Miller thinks the state simply needs "more boots on the ground," but, he says, the mechanisms are in place for state school residents to report abuse, and if advocacy groups and legislators continue to push for residents and funding to go from state schools to community homes, those standards should move, too.
"We've been taking a bath with all the stories from the state schools," Miller says. "But nobody seems to see the importance of looking as closely at these places in the community."
The Department of Aging and Disability Services doesn't release details of investigations at private homes, so it's tough to gauge the extent of the abuse in those facilities, if it exists.
But during the summer of 2008, a mentally challenged man living in a community home was found overheated in a van and later died, according to a press release from the Houston Police Department.
Carlos Jackson was a resident at Belltech Enterprises, Inc., which runs a dayhab, or day rehabilitation center, near Richmond Avenue and Highway 6. Jackson, along with other clients, was riding from a dayhab to his home when the van broke down at a gas station. Another vehicle picked up the stranded clients, but by the time they got him to the hospital, it was too late for Jackson and he died later that day.
The police department says it is investigating the death, which was ruled accidental. Fedorov didn't have any information on a DADS investigation.
Even if the agency did investigate, the state doesn't categorize deaths in private homes, so there is no way to tell if Jackson's death was caused by abuse or neglect or simply by natural causes.
On a rainy morning in April, Linda Falk stood with two other women in the offices of the Four J's Community Living Center, Inc., which runs a day rehabilitation center in a business park not far from Sharpstown Mall.
The other women, Ilene Robinson and Sandra Reeves, also have relatives — a sister and a son — in Richmond State School, and with the push to move residents out of the institution, the ladies wanted to see the alternatives.
Waiting in the lobby of Four J's, Falk felt a chill. Every experience she had had with Trevor in a private group was bad, and the cold offices at Four J's didn't ease her fear.
After a ten-minute wait, a caseworker appeared from behind a locked glass door to show the women the dayhab rooms. They walked through a neatly landscaped courtyard through another locked door to see the high-functioning group, patients with some level of independence. It was lunch time and about 20 residents were sitting at white plastic tables eating prepackaged sandwiches from Sysco.
Across the hall, on the low-functioning side, the scene was a bit more chaotic.
Several caregivers served patients mashed potatoes on paper plates, and in one small room, about ten people in wheelchairs were crammed along one wall. A man sprawled on a hospital bed with no sheets, and another girl rested her body across the armrest of a recliner.
Other clients who weren't eating sat in plastic chairs on another side of the building or roamed around a room about the size of an elementary school classroom. A woman named Linda, who couldn't speak but was angry and crying, hit one of the caregivers several times in the chest before banging her head against a concrete wall.
After leaving the facility, Falk and Robinson stood in the parking lot and hugged, both on the verge of tears.
"There's a racket out here. The group homes are what the Department of Justice is not looking at, at all," Robinson says. "What they think goes on and what really goes on are two totally different things."
Anthonia Uduma, who owns Four J's, declined to speak with the Press.
The Press visited about a dozen other dayhab centers and residential group homes in the area, and most of the facilities were similar, located in strip malls or business parks.
One place, D&D Care Homes, Inc., on the far southwest side of the city, was nice. Almost all of the 45 residents there were high functioning, and the facility had rooms with brand-new computers and exercise equipment. Private tutors are brought in each day to teach residents a variety of subjects, such as arts and crafts, spelling or reading. A trip to Europe for the group is planned for 2012.
The other facilities were mostly filled with tables where residents sit for six to eight hours a day, watching television, coloring with crayons or working on some other menial task.
"There are actually a lot of people in dayhabs that could work in the community and be taxpaying citizens, and [dayhabs] were initially created to train people for work," says Choate. "But what it basically ended up being is a warehouse and babysitting system."
In the for-profit system, providers sometimes compete for clients, and no other population is more sought after than the residents at state schools. About 37,000 Texans are waiting for the Medicaid waivers that pay for the private group homes — some have been waiting as long as nine years — but state school residents who want to leave are guaranteed a spot in the private homes.
Despite this guarantee, moving out doesn't go quickly. Fedorov says each person who wants to leave a state school is counseled on community living, and any potential provider is screened to determine if his facility is a good fit.
"When someone decides they want to move out of the state school, it doesn't just happen overnight," she says. "There is a lengthy review process."
But residents are leaving. Last year, Richmond State School lost about 20 residents to private homes, according to Barrera. That's at least $94,000 of new revenue per month in the private system.
"It's turned into a very lucrative business for these private providers. They figured out they can make a lot of money caring for this population that can't really complain," Miller says. "That's fertile grounds for abuse."
After Governor Perry made a priority of protecting state school residents, Miller was worried that protection translated to closing the schools in favor of private homes.
"There were at least six or seven bills that could've put us out of business," he says.
One of the strongest bills against Richmond was authored by state Senator Rodney Ellis, a Democrat who represents parts of Harris and Fort Bend counties but not the state school, to develop a strategic plan that would, among other things, "transfer funds from institutions to community-based strategies" and "identify the number and location of state schools and state centers that will be closed under the plan."
The Ellis bill eventually died, but much of the same wording transferred to a similar bill filed by state Senator Judith Zaffirini, a Democrat from Laredo. Near the end of the legislative session in May, two items remained in that bill that scared state school supporters. One would allow a state school caseworker to override a guardian's decision for a resident, and another would cause funding to move from the state school to private homes.
Reeves and Robinson, along with Ferguson and Miller, traveled to Austin to testify, and the two items were eventually removed from the bill.
About the same time, the state reached an agreement with the Justice Department to vastly improve the care of residents in state schools, focusing on increased training of staff. The dollar amounts haven't been finalized, Fedorov says, but she expects about $24 million to be injected into the state school system each of the next two years.
"We survived, and it's been nothing short of divine intervention," Miller says.
The worst four months for Trevor Falk were during the spring of 2006.
It started when he moved from his mother's house to live with his father. One afternoon while his father was at work, Trevor got in an argument with his stepmother that escalated into a shoving match. She fell down and broke her foot.
The police were called, and Trevor was sent to the Harris County Psychiatric Center, a short-term care facility where patients can stay up to a month. He was discharged after three days, starting his journey through the 13 group homes.
"He couldn't come to my house because I could not control him behaviorally at that time," Linda Falk says.
Trevor was asked to leave most of the private homes for causing trouble, and sometimes the explanation was that he broke furniture, sometimes he slammed a door.
"I picked him up one time and he stayed at my house for three days, and they had him so drugged that I wasn't having problems with his behavior," Linda Falk says. "But he had to go back."
After Trevor was kicked out of another home, his father, David Falk, went to get him, but none of Trevor's clothes were clean. The dryer in the house had broken, David Falk says, and the clients' clothes were left in the garage to dry.
"There's something wrong with that system," he says.
Another time Trevor was missing his radio and electric razor after he left.
"It was nothing but eight-foot tables, and the clients were sitting there twiddling their thumbs. No TV, nothing," Linda Falk says. "And they were stealing him blind."
Trevor finally settled into a group home he went to, but he called his mother one weekend and asked if he could come to her house for a couple days. She picked him up from the home in far north Houston, and while he was with her, Trevor was quiet and scared.
Linda took him back on a Saturday evening, and the following morning, he called her from a gas station pay phone, screaming for her to come get him.
"I said, 'Where are you, Trevor?'" Linda Falk says. "He said, 'Little store, down the street. Boy hit me; boy beat me up. I ran away. Come get me. Hurry, Mom.'"
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After he was sent to his final group home, Linda Falk wrote a letter to his caseworker, outlining the events of the previous months and asking for help. Trevor moved to Richmond State School.
Trevor has thrived since moving there, and his behavioral problems have all but disappeared. One weekend Linda Falk picked up Trevor, took him to a movie and asked if he wanted to spend the weekend at her house. He wanted go back to the state school to be with his friends, he told her.
"He's in a very unrestrictive unit, and he's so proud of it," Linda Falk says. "He feels like that's his kitchen, that's his dining room, that's his home."