State mishandled cases of abuse, neglect of some of Virginia’s most vulnerable: audit
VENN
RICHMOND, Va. (WRIC) -- The state failed to properly investigate many allegations of abuse, neglect and exploitation of some of Virginia's most vulnerable, according to a new audit report.
On Friday, Sept. 26, the Office of the State Inspector General (OSIG) released the findings of an audit of the Virginia Department of Behavioral Health and Development Services (DBHDS), which oversees the Commonwealth's public behavioral health and developmental services system.
State auditors examined records of DBHDS investigations into abuse, neglect and exploitation within its facilities and found many instances where said investigations were not carried out properly.
Specifically, OSIG shared the following findings:
- Allegations and investigations were not handled promptly. Dozens of allegations of abuse and neglect were found to have not been reported or investigated promptly, as required under state law.
- Investigations were not carried out properly. More than half of the cases that state auditors examined were not conducted correctly -- from mishandled interviews to an overall lack of due diligence.
- Investigations were not documented properly. Required documentation was found to be missing from many cases -- including vital details, in some instances. State auditors also identified multiple issues with how DBDHS stored case data.
- Investigations were not resolved appropriately. Despite investigators finding evidence that proved misconduct occurred, DBHDS did not resolve the case accordingly in several instances. Other kinds of mismatched results were also noted.
- Corrective actions were not completed in a timely manner. In instances where corrective actions were required, said actions were not always carried out by their respective deadlines.
State auditors described some of these missteps not only as failures to comply with state law, but critical issues that put patients at risk and undermine trust in the system.
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Keep reading for more detailed information on the issues state auditors identified and OSIG's recommendations.
Who receives care at these facilities? What rights do they have?
DBHDS operates 12 facilities, which provide care and treatment to a wide variety of people -- including children, older adults, those with complex needs and those with serious medical conditions, OSIG said. More than half of these facilities cater to those with psychiatric conditions, intellectual disabilities and/or behavioral health needs.
Four of these facilities are located in Central Virginia, including:
- Central State Hospital in Dinwiddie County
- Hiram W. Davis Medical Center in Dinwiddie County
- Piedmont Geriatric Hospital in Nottoway County
- Virginia Center for Behavioral Rehabilitation in Nottoway County
Under Virginia law, individuals receiving care within DBHDS facilities are guaranteed the right "to be treated with dignity and respect, to be free from abuse and neglect, and to receive
appropriate care and treatment based on their understanding and needs," OSIG said.
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To ensure that the law is followed and that these rights are protected, DBHDS accepts and then investigates complaints concerning possible abuse, neglect and exploitation. There is an established framework for how these cases should be investigated, state auditors said.
OSIG's audit, which examined DBHDS activities from July 1, 2023 through July 31, 2024, was performed to check in on the effectiveness of these investigations.
State auditors randomly selected 190 investigations from this period and used these findings to approximate how many of the total 524 investigations likely have the same issues.
Audit: Allegations were not handled with urgency
Delays and gaps in communication were found at many points of the investigatory process. This included backlogs in reporting allegations, carrying out investigations and reporting their results to the necessary personnel.
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Of the 190 cases state auditors examined, allegations were not reported to the DBHDS facility's director immediately, as required, in 41 instances. Other important staffers involved in this process were not immediately notified in as many as 116 instances.
Actual work did not begin promptly on 71 of the 190 cases. On average, victims were interviewed after six days, the first witness after eight days, the last witness after 12 days and the accused after 11.
Such delays compromise investigations, OSIG said.
"Memory degradation can begin rapidly after an event," state auditors said. "Interviews conducted beyond one week are associated with increased memory distortion and reduced reliability, especially in vulnerable populations."
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Finally, in 62 instances, the staff member accused of abuse, neglect or exploitation was never told about the investigation's findings.
Based on these results, state auditors estimate that at least 30% of all DBHDS cases from the auditing period were not started promptly. Additionally, hundreds of cases are estimated to have at least one communications-related issue.
Staff did not investigate properly, nor in good faith
State auditors found several issues with how DBHDS staff conducted their investigations.
More than 60% of the cases OSIG examined included interviews that were not conducted properly. This included staff not interviewing all relevant people, staff taking statements incorrectly or not at all and staff conducting interviews inappropriately.
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Nearly 40% of cases were "not performed with due diligence." This included staff not evaluating discrepancies between pieces of evidence, incorrectly valuing one piece of evidence over another and choosing not to pursue other issues of abuse or neglect when discovered.
It's estimated that at least 57% of all investigations from the auditing period have improperly-conducted interviews and that at least 31% were not performed with due diligence.
Further, OSIG found multiple instances in which an allegation was labeled as "improbable" -- and therefore not investigated -- without the necessary steps being taken. While DBHDS does have a process for deeming allegations "improbable," this is meant to be done only after thorough assessment.
State auditors examined 23 cases where their allegations were decided to be "improbable" and found that the appropriate steps were followed in only 30% of the cases. In the remaining 70%, investigators erred in a variety of ways, including by not consulting with the patient's treatment team and/or not having the patient clinically assessed.
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State auditors learned that investigators "often lack the necessary skills and knowledge to conduct investigations appropriately, even with the required training." They are often existing employees whose primary job responsibilities aren't related at all to investigations.
"One investigator noted, 'If it was not for my background in law enforcement, I could not adequately do this job,'" OSIG said.
Case information was missing, not documented correctly
Complimenting the issues explored above, state auditors also learned that there are several problems with how investigations are documented.
In 85 of the examined cases, staff did not include a well-written investigation summary with required items like an investigation timeline, review of evidence and the investigator's rationale, among others. At least 38% of all cases are believed to have this issue.
Relevant evidence, such as photos of injuries or surveillance footage, was not included in 57 instances. At least 31% of all cases are believed to be missing such evidence.
Discovered issues with surveillance cameras at five facilities only make matters worse. In some cases, footage wasn't stored for the required amount of time under state law -- in others, cameras were found to be blocked, malfunctioning or broken.
Without footage, not only are both internal investigations and potential prosecution hindered, but those who would seek to harm patients can do so more easily, state auditors said.
OSIG found that one of the systems used to log case data is limited by its capabilities, design and programming. Much of the data entered into it was also found to be incorrect or incomplete. For example, some cases were closed in the system despite not being finished. In other cases, the data in the system directly contradicted the true findings of the investigation.
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More than that, depending on the case, staff may have to enter case data in three different systems. Staff told state auditors that this was frustrating, describing it as "tedious and cumbersome." They added that they "often had to develop their own ways internally to track and monitor information that was also entered into these systems."
Both these findings and those related to investigation quality are due to deficiencies in training, oversight and qualifications, according to state auditors.
"As a result, critical aspects of abuse and neglect allegations may be overlooked, improperly documented or handled inappropriately, which compromises the integrity of the investigative process," OSIG said. "This ultimately puts patients at risk and undermines trust in the system."
Appropriate actions were not taken when abuse was found
Facility directors are ultimately responsible for the final determination, or conclusion, of an investigation, OSIG said. In 30 of the reviewed cases, state auditors found that the decided-upon conclusion did not match the findings of investigators.
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Of these, more than half were found to have been inadequately investigated, with more work needed before an accurate conclusion could be formed.
A dozen of these cases should have been substantiated -- or confirmed to contain true allegations of abuse, neglect or exploitation -- based on evidence collected, but they were not.
State auditors estimate that at least 10% of all cases from the auditing period have errors like these.
Even when ordered, corrective action wasn't taken swiftly
As with the final determination of a case, facility directors are also responsible for ensuring that the necessary corrective actions are taken.
A total of 76 cases examined by OSIG required corrective action to be taken. However, in over 40% of those cases, corrective action wasn't taken in a timely manner -- or taken at all.
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In 32% of those cases, there was no documentation to support that action was taken.
State auditors' recommendations
OSIG provided DBHDS with over 30 recommendations as a result of this audit. Some of those recommendations include:
- Develop a comprehensive certification program for investigators, to include in-depth training on how to interview, collect evidence and document findings.
- Adequately review investigation reports to ensure they contain relevant information.
- Ensure facility directors follow through with corrective actions and do so in a timely manner.
- Reinforce the importance of performing interviews in a timely manner, especially with the alleged victim and any key witnesses.
- Create a system in which all incidents can be managed and documented.
- Make sure all facilities have functioning surveillance cameras and that they are maintaining footage for the state-required amount of time.
The DBHDS affirmed the conditions state auditors found and agreed to the suggested corrective actions.
To read the 42-page audit in full, click here.
