After sexual assaults and ‘alarming’ deaths in care centers, Disability Law Center asks feds to investigate Utah licensers

The nonprofit accuses Utah licensing officials of allowing programs to stay open even after vulnerable people have died or been seriously harmed.

Utah agencies that oversee long-term care facilities have prioritized helping problematic programs stay open — rather than shutting them down after vulnerable people have been harmed, the Disability Law Center argues in a new complaint to federal authorities.

The nonprofit, which is tasked by the federal government to look into the way Utah manages its care homes for the disabled, said it’s been raising the alarm for more than a decade urging Utah’s Department of Health and Human Services to address systemic failures in how it regulates centers.

But the Disability Law Center says the pattern of allowing dangerous programs to stay open has continued — and the nonprofit, along with the National Health Law Program, on Tuesday filed a complaint asking the federal government to step in and investigate.

Nate Crippes, the public affairs supervising attorney for the Disability Law Center, said his organization has been bringing instances of sexual abuse and death to state licensers since 2014.

“Unfortunately, the State has failed to take the action necessary to prevent these harms,” he said in a statement, “so we are calling on federal regulators to step in and ensure Utahns with disabilities are kept safe.”

The complaint was sent to the Centers for Medicare and Medicaid Services, the Office of the Inspector General, and the Office for Civil Rights within the U.S. Department of Health and Human Services.

The complaint asks the Medicaid office to cancel contracts with problematic facilities in Utah which receive this funding and are not meeting minimum safety standards. It requests the inspector general to examine the use of federal funds to monitor and pay facilities that Utah authorities know are dangerous. And it seeks for the civil rights office to investigate whether Utah licensers are effectively communicating with people with disabilities who are making complaints.

The Disability Law Center highlighted several deaths in Utah long-term care facilities in recent years in its complaint:

  • A 48-year-old man named Chien Nguyen lived at a Midvale facility that local health authorities shut down after finding the home had been overflowing with raw sewage, had a bedbug infestation and had no smoke alarms or appropriate fire extinguishers. He later died by suicide at another care facility. The second facility was allowed to remain open until its owners were charged criminally in connection with Nguyen’s death.

  • At another facility, a 12-year-old girl died of sepsis due to a kidney infection in November 2021. Three months later, at the same facility, a 64-year-old woman who was supposed to be monitored while eating was left unattended and choked over several days before she died. State licensers responded to her death by fining the facility $200. It was allowed to continue to operate for more than a year before it voluntarily relinquished its license.

  • A 16-year-old boy died last October after he stole a car and police officers shot and killed him. The report says the boy was autistic, had a history of stealing cars, and his residential provider was supposed to have hired staff to watch him. That didn’t happen, and the program also didn’t put locks on doors and windows as the boy’s treatment plan required.

The complaint said that based on these deaths and other allegations of abuse, it’s unclear what kind of misconduct would ever warrant a facility losing its license.

The Disability Law Center also pointed to the state’s handling of Highland Ridge Hospital, a psychiatric hospital where licensers had documented failures to respond to sexual assault, as well as inappropriate chemical restraints and seclusion. Despite state authorities threatening to pull its license three times, Highland Ridge remained open until it made the choice to relinquish its license in April.

The nonprofit has released reports critical of state licensers in the past. In response to a 2023 report which largely focused on Nguyen’s death, DHHS Executive Director Tracy Gruber called the Disability Law Center report “important, but not the whole story.” In an opinion piece for The Salt Lake Tribune, Gruber said “the state must navigate a balance” between ensuring there are safe places for people to be cared for, and that enough private programs remain available for those people to live in.

“When our department fails to strike that balance, we risk reacting too quickly to close a program without a safe placement for individuals in that program to live,” she wrote. “In many cases, they can’t simply go home. Who would care for these individuals? Where would they go? So, our department works with providers when possible to correct problems. Facility closures occur when corrective action plans fail to be implemented effectively.”

Joe Dougherty, the communications director for DHHS, said in a statement Wednesday that the department agrees with some of the points that the Disability Law Center has raised.

“We agree that individuals should get the services they need in safe and healthy environments,” he said. “We agree that providers who fail to adequately care for individuals in their services need to improve that care or lose their license.”

He noted that DHHS ended its contracts with the programs that had been serving the teen who was killed in the police shooting, and their licenses were later revoked. And Highland Ridge, he said, decided to close rather than come into compliance with the strict sanctions DHHS handed down earlier this year.

When programs want to improve and comply with rules and standards, Dougherty said, DHHS helps them get there. But if they aren’t willing to comply, he said, “we impose penalties and restrictions, and we revoke licenses.”

Dougherty noted that the department has gone through a transformation in the last two years, after the health department and human services merged to be more efficient. He said implementing new processes take time — and that DHHS is required to both protect Utahns and ensure services are available to them.

“So there are serious concerns when Utah has fewer facilities to provide needed services for vulnerable people,” he said. “Utah DHHS cooperates and engages with partners on all levels who will help move the work of building and protecting people forward.”