After a year-long review of how Multnomah County handles reports of abuse and neglect of individuals with mental illness, the Multnomah County District Attorney on Tuesday said he found no criminal wrongdoing on the part of County staff.
County administrators had asked the District Attorney and Multnomah County Sheriff’s Office to review staff work after the County launched an internal investigation in August 2018 upon learning that some complaints related to people at Unity Behavioral Health had not been forwarded for further investigation or protective services. The Adult Protective Services reporting line is managed by the Health Department’s Mental Health and Addiction Services Division.
To conduct the internal investigation, Chief Operating Officer Marissa Madrigal directed managers in the Department of County Human Services who have expertise in adult protective services to review all complaints that had been “screened out’’ between the time the Unity Center opened in January 2017 through August 2018. Madrigal also then sought the assistance of the District Attorney and Multnomah County Sheriff’s Office to independently review those reports.
In reviewing more than 1,330 reports, the Human Services team sought first to determine whether any potential victim was at an immediate risk due to an incorrect screening decision. They found no one at immediate risk. They also offered services to potential victims.
The reviewers did find response protocols and practices muddied by contradictory state reporting requirements, inconsistent documentation, a lack of oversight at Mental Health and Addiction Services Division and staff shortages. The County then forwarded its findings to the District Attorney and Sheriff offices to determine whether any employees could be held criminally responsible for the failures to follow up on complaints.
“We’re grateful for the thorough review from the District Attorney's office, Multnomah County Sheriff's office and the Department of County Human Services,” said Madrigal. “Their analysis has given the County an opportunity to take responsibility and better protect the public.’’
Since August 2018, the County also instituted sweeping personnel changes in the Mental Health and Addiction Services Division, appointing a new director and revamping the training, reporting and supervision of the staff receiving the complaints.
“The Division is now operating in accordance with the seriousness and attention to detail appropriate to this level of responsibility,’’ Madrigal said. “Today, every referral gets a thorough review. Staff get the supervision, support and training they need. And the Division is clear about its reporting requirements.”
Pending rules lead to confusion
Changes in the County’s handling of reports date to July 2017 when the state, through the joint Office of Training Investigation and Safety of the Oregon Health Authority and Oregon Department of Human Services, shared pending rule changes on abuse investigations with county mental health adult protective services programs. Starting in September 2017, the state said, county mental health programs could investigate allegations of abuse or neglect only on behalf of people receiving services from a licensed facility or a community mental health program in their jurisdiction.
That meant that if an alleged victim were not staying in a residential facility or engaged in mental health services with the county, the county could not launch an investigation.
But in cases that didn’t fit the state’s new standard for investigations, state officials expected counties to continue providing protective services in cases it could not investigate. And, in cases where there was a question of a crime, the state also expected counties to alert law enforcement. Instead, in Multnomah County, screeners in mental health adult protective services did not provide protective services or refer cases to law enforcement in many cases when they should have.
Almost a year later, by August 2018, state officials adopted a new administrative rule that once again broadened the counties’ authority to investigate abuse. By then, County leadership had learned of the Division's mistake through questions raised by The Oregonian, The Lund Report and Portland Tribune about the County’s handling of complaints of abuse and neglect from patients at the Unity Center for Behavioral Health.
COO orders retrospective review
That month, the County launched an investigation of Mental Health and Addiction Services Division’s handling of complaints of abuse and neglect. Chief Operating Officer Madrigal placed two Division administrators on leave, and asked senior managers with the Department of County Human Services to review every referral that the Division received and immediately screened out since January 2017.
The Department of County Human Services conducts adult protective services both through its Aging, Disability and Veterans Services Division and its Intellectual and Developmental Disabilities Division. The department assembled a seven-person review committee led by Director Peggy Brey and Deputy Director Mohammad Bader.
The team included quality assurance and management supervisors, as well as reviewers and analysts. It reviewed whether the reports of abuse were handled in compliance with State rules and, in particular, looked at referrals for protective services (referrals to other County departments, State offices, and community-based organizations that could provide services, safety plans and related supports) and referral to law enforcement when there was question of a crime.
In total, the team spent six weeks reviewing 1,338 reports. Of those:
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136 cases should have been reported to law enforcement but were not.
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94 cases were screened out when an investigation of abuse or neglect should have occurred.
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210 cases were screened out without additional protective services.
Although the initial spotlight was on Unity, where 21 referrals were made, of those, two cases should have been referred to law enforcement and information was not clear enough in three others to make a determination.
When the reviewers completed their report in October 2018, Madrigal submitted the findings to Multnomah County District Attorney Rod Underhill and the Multnomah County Sheriff’s Office.
The Department also forwarded its findings to the Mental Health Adult Protective Services program, which responded to the findings with a quality improvement plan to prioritize cases with the greatest risk and safety concerns.
Detectives with the Multnomah County Sheriff’s Office and with the Oregon State Police interviewed witnesses and people involved in the screening process while the District Attorney's Office interviewed still other witnesses, and reviewed County emails and training materials.
The District Attorney was to determine whether any county employee should be charged with official misconduct for failing, as mandatory reporters of abuse, to notify law enforcement in cases where a crime might have occurred.
To be criminally liable for official misconduct, District Attorney Underhill wrote Monday in his decision to Chair Kafoury, a public servant must either knowingly violate a law related to that person's office or with the intent to obtain a benefit or to harm another, must knowingly fail to perform a duty imposed by law or clearly inherent in the nature of the office.
“There is insufficient evidence to establish that any county worker knowingly violated statutes relating to the office of the person,” Underhill wrote, “that any county worker obtained or intended to obtain a personal benefit or that any county worker intentionally harmed or intended to harm another person by not notifying law enforcement about abuse reports.”
Sweeping Change
In the midst of the review, the Board of Commissioners appointed Ebony Clarke as interim director of the Health Department's Mental Health and Addiction Services Division. In March, she was permanently appointed director. Under her leadership, and in partnership with new Health Department Director Patricia Charles-Heathers, the Division made sweeping changes to its adult protective services program.
The Division reorganized oversight to better support the program, and hired three additional staff. They included a risk case manager who is referred cases that might not meet requirements for a county investigation but where safety concerns remain. The Division created a program supervisor position to oversee the team — and to immediately review every decision her team made on whether to screen out a referral, when to refer a case to law enforcement, and how to ensure each person was safe and connected to social services.
The Division also established documentation standards, increased consultations with legal counsel, and documented screening rules and processes to help screeners make their abuse determinations. It established protocols for onboarding new employees and mandatory trainings for existing staff. Those trainings cover topics including screening and documentation requirements, law enforcement notification and safety planning. The Division also increased training for community partners and mandatory reporters who might need to make a referral.
“Keeping people who are in a crisis safe is at the absolute core of the County’s work and mission,’’ said Chair Deborah Kafoury. “We must continue to rigorously examine our policies and practices and hold ourselves accountable. We are the safety net. And people must be able to depend on us. Our community deserves no less.”