Christen Gordon became a ward of the state when she was 9 months old. Disabled since birth, she would never walk or talk, never dress herself or eat on her own. She would never live a day without constant assistance.
For a decade, she got that support at Central State Hospital in Milledgeville. By all accounts, she thrived. But then, in 2012, the state outsourced her care to a for-profit corporation.
Fifteen months later, she was dead. She was 12 years old.
The final months of Christen Gordon's short life highlight the government's increasing reliance on private companies to perform what has long been considered a societal obligation: caring for people with mental illness and developmental disabilities.
Across the nation, a multi-billion-dollar industry that runs group homes and other small, community-based facilities has largely supplanted public institutions. At places like Central State, residents lived in isolation and in danger, suffering abuse and neglect that often had tragic consequences. But at many privately run homes, inadequate staffing, poor training and incessant cost-control measures have put their residents at a similar risk, an investigation by The Atlanta Journal-Constitution found.
In Georgia alone, 53 people died under the care of two of the nation’s biggest for-profit companies between 2014 and 2016, the Journal-Constitution found. At least 46 of the deaths were unexpected and may have been preventable, state reports suggest.
The private firms have assumed responsibility for many of the state's most vulnerable dependents, who have complicated medical and behavioral needs and require specialized treatment. Georgia contracts with about 200 such companies, none larger than the one that took over Christen Gordon's care: ResCare Inc.
Owned by a Canadian private equity firm, ResCare is based in Louisville, Kentucky, and operates in 42 states, serving 60,000 clients with 45,000 employees. In 2016, it reported $1.8 billion in revenue, with $28 million in profit. The company maintains its profitability in a volatile industry, its former chief executive once told financial analysts, by cutting staff, combining group homes and buying up smaller competitors.
The Journal-Constitution reviewed dozens of lawsuits, government investigations and news reports concerning deaths in ResCare facilities across the country. The review found poor care, abuse and neglect – all, critics contend, stemming from a drive to increase profits.
“They try to do things as cheaply as they possibly can to save money,” said Robert Hallack, a lawyer in Baton Rouge, Louisiana. Hallack is suing ResCare on behalf of Christopher Templeton, 28. Templeton, who has cerebral palsy and autism, spent seven years in one of ResCare’s group homes. His treatment, the lawsuit alleges, left him in a hospital, dehydrated, covered in pressure sores and fighting for his life.
"They weren't feeding him, they weren't giving him fluids," Hallack said. "He would have died if he had stayed in that group home any longer."
ResCare has denied the lawsuit’s allegations, saying it had no responsibility over whoever harmed Templeton. A trial is scheduled in 2018.
The company’s executives declined to be interviewed. In a statement, its chief clinical officer, Rachael Kurzer Givens, said ResCare is “constantly improving and developing new solutions that increase safety and the quality of care delivered.”
ResCare, Givens said, spends about $125 million a year on “clinical, quality and training programs” without reimbursement from government agencies. The company’s challenges, she said, are no different than those facing others in the industry.
Angelyn Dionysatos, a spokeswoman for the Georgia Department of Behavioral Health and Developmental Disabilities, said she could not discuss “a provider or any specific cases related to the provider.”
Deaths and injuries under the supervision of ResCare and other for-profit companies raise fundamental questions about outsourcing care for the disabled and other social services.
Government agencies can use "meaningful metrics" to hold contractors accountable for good care, said Leonard Gilroy, editor of the Reason Foundation's Annual Privatization Report.
But Donald Cohen, of the advocacy group In the Public Interest, said the practice siphons away some of the already inadequate funding for social services.
"There just is not enough money to add profits to the equation," Cohen said. For the companies, "it's all about the pot of gold."
In Georgia, under a regulation that took effect April 1, companies must spend at least 60 percent of their government payments on direct care. Previously, the state imposed no cap on overhead costs and profits.
‘An interesting patient’
Severe mental retardation. Developmental delay. Seizure disorder. Microcephaly. Cerebral palsy. Autism.
Christen Gordon’s disabilities were remarkable both for their number and their severity. She was born March 13, 2001, with only three chambers in her heart, rather than the usual four. From the start, she breathed and ate through tubes. She remained in the hospital for months before her mother, LaTasha Gordon, placed Christen in state custody.
She ended up at Central State, Georgia’s oldest psychiatric hospital and, over the past century and a half, the lifelong home of tens of thousands of children and adults with disabilities. Officials admitted Christen to a nursing home on the Central State campus, and she quickly became a staff favorite.
“Everybody was taking care of her and loving on her,” said Faye Smith, a former state legislator from Milledgeville who became Christen’s teacher at Central State. “She was a very alive little girl. She loved attention.
“She grew and she grew,” Smith said. “She made a beautiful little girl.”
Like so many others before her, Christen might have spent the rest of her life at Central State. But in 2010, Georgia signed an agreement with the federal government to change the way it served people with developmental disabilities and severe mental illness. The goal was to integrate disabled people into their communities, and most would be moved from institutional settings like the state hospitals to small group homes or even private residences – including those, like Christen, with the most complicated medical conditions.
A Macon couple, Fred and Juliet Ssenjakko, had signed on with ResCare to become caregivers. Fred was a registered nurse, Juliet a licensed practical nurse. They were seeking, Fred Ssenjakko later told a state investigator, “an interesting patient.”
On May 15, 2012, the Ssenjakkos moved Christen, then 11, into their five-bedroom home on a cul-de-sac on Macon’s west side. She would provide the challenge they wanted.
Christen communicated only by whining or crying, rocking back and forth or hitting herself. She required 24-hour care: feedings during the night and someone to make sure she didn’t wake up and hurt herself. Her medical records said she was at risk of falls, constipation, malnutrition and aspiration, among other maladies.
ResCare would pay the Ssenjakkos $200 a day for around-the-clock care. A state-paid “support coordinator” would visit at least once a month to check on Christen. And a ResCare nurse was supposed to spend 12 hours a month in the home.
Christen remained a ward of the state, but she was no longer under its watch.
When she moved into the Ssenjakkos’ home, Christen was stable, despite her disabilities, according to court records. But in June 2013, her doctor documented an eight-pound weight loss over four weeks, along with redness in her stool. Four days later, she entered a Macon hospital, newly diagnosed with autoimmune hepatitis and lupus.
Christen ran a persistent fever over the next few weeks, medical records show. Her white blood-cell count registered way above normal levels. Her heart raced. She cried from the pain.
Faye Smith, who had taught Christen at Central State, visited her in the hospital. Smith sat on a windowsill one afternoon, holding Christen’s hand.
"She was absolutely skin and bones," Smith said. "Her little eyes were – she wasn't there."
‘Vulnerable target’
More than five years earlier, police were called to another ResCare home in Georgia. In Columbus, officers found the body of 37-year-old Carolyn Lunsford, apparently kicked to death by Carolyn Davis, whom ResCare had hired as her caregiver.
Davis had become frustrated, she said later, because Lunsford kept wetting her bed. But authorities found not just fresh injuries, but also older wounds on Lunsford’s arms, legs and torso. Those had somehow escaped the notice of a case manager who had visited eight days earlier.
On trial, Davis contended ResCare failed to adequately train her to manage a difficult client. But a judge imposed the maximum sentence for voluntary manslaughter: 20 years.
The case reflects several themes that emerged in the Journal-Constitution’s review of more than five dozen deaths in ResCare facilities over the past two decades.
Caregivers often received little or no training. Their pay was low — lower than that of the company’s maintenance workers, in at least one instance. And in many homes, ResCare didn’t employ enough caregivers to do the job.
In several cases, courts have held ResCare accountable for these deficiencies.
After Christine Zellner, 23, died in a ResCare group home in Kansas in 1996, authorities determined the facility was understaffed, its food budget had been cut and training was inadequate, according to court records. Zellner apparently went without food for the last four days of her life.
“The conduct of ResCare resulted in the death of a mentally retarded woman, who was a much more vulnerable target because of her retardation,” a federal judge wrote in a civil case filed by Zellner’s family. In 2002, a jury awarded Zellner’s family about $4 million. ResCare ultimately paid $747,500 to settle the lawsuit.
In 2009, a jury in New Mexico ordered ResCare to pay $54.2 million to a 48-year-old developmentally disabled man who was raped in a company group home five years earlier. ResCare had fired 10 employees at the facility for illegal drug use and quickly hired replacements. One of the new workers had molested a patient when he worked at another facility, but ResCare didn’t check his history. Nor did it train him before putting him to work. On his first shift at the group home, the employee entered the resident’s bedroom and raped him.
A judge reduced the verdict to $12.8 million. ResCare still appealed, but later negotiated an undisclosed payment to the man and his family.
ResCare employees also have been victims.
In January, police in Kentucky charged a resident of a ResCare group home with killing Sally Berry, a 66-year-old caregiver. Authorities said Lindale Cunningham, 32, attacked Berry with a steak knife, stabbing her 139 times. Cunningham, who had previously threatened a caregiver, stood a foot taller than Berry and outweighed her by 100 pounds. Berry was working alone, supervising three male residents. Another employee found her body when the shift changed.
ResCare would not answer questions about these or other cases. In a statement, the company said, “We are deeply saddened by situations where an employee or client is harmed in any way.”
Critics, including lawyers who have sued ResCare, say the worst outcomes are a natural consequence of the company’s business model: constantly cutting expenses to ensure profits.
ResCare’s former chief executive, Ralph Gronefeld, described the company’s approach in a conference call with financial analysts on Aug. 6, 2010. At the time, an economic downtown was causing some state governments to reduce payments to the company. But Gronefeld told the analysts the company could absorb two-thirds of the reductions without affecting profits or the quality of care.
“We pull cost out,” he said, according to a transcript of the call. “We look at our staffing. We look at a consolidation of homes.”
“We’re profitable in every state that we’re in,” he said.
Gronefeld retired last year. ResCare did not answer written questions about his comments.
Assigning blame
Early on Aug. 24, 2013, home from the hospital, Christen Gordon’s fever had broken. But when Fred Ssenjakko fed her at 4:46 a.m. and again at 6:30, she remained irritable and restless.
Juliet Ssenjakko entered Christen’s room at 7:30, she said later. Christen raised herself on an elbow, just for a moment. Then she collapsed.
Neither Juliet Ssenjakko nor paramedics could revive her. An emergency room doctor pronounced Christen dead at 8:46 a.m.
A deputy coroner in Bibb County said Christen probably died of a heart attack, but he did not order an autopsy.
Almost immediately, virtually everyone involved in Christen’s care began blaming one another for not preventing her death.
Fred Ssenjakko told a state investigator that ResCare had promised to assign another caregiver to help with Christen. “They said they pay for awake staff all night,” but the company reneged, he said.
Peggy Clay, executive director of ResCare’s Macon office, suggested to the investigator that money motivated the Ssenjakkos. They had resisted signing a contract renewal until ResCare agreed to pay them more to care for Christen.
“Fred said her care was his only job,” Clay told the investigator, “and wanted $200 a day because it was his only job.” Actually, according to court records and the investigator’s report, Ssenjakko had another nursing job.
Regardless, “they did not want anyone else in their home,” Clay said, according to the investigator’s notes. “Fred said he would stay awake with her at night.”
A support coordinator hired by the state told the investigator that ResCare’s nurse, who was supposed to spend 12 hours a month with Christen, hadn’t visited in months. “The family felt unsupported,” the coordinator said.
Finally, Christen’s mother, LaTasha Gordon, filed a lawsuit in 2015, blaming both ResCare and the Ssenjakkos, as well as a doctor, for the death.
“I want justice,” she told the Augusta Chronicle at the time.
In court filings, ResCare said it did not “breach any duty of care owed to Christen Gordon.” The Ssenjakkos’ response said Christen came to them with multiple health problems and they provided appropriate care. Through their lawyer, the Ssenjakkos declined to comment. The lawsuit is pending.
The state cited ResCare over the lack of nursing care but imposed no penalty. ResCare remains the state’s largest provider of services for people with disabilities; in the 2016 fiscal year, Georgia paid the company and its subsidiaries $79.3 million. State officials have no plans to curtail the use of for-profit companies.
Christen Gordon is buried in Wrens, Georgia, a small town where she never lived, about 30 miles southwest of Augusta. Faye Smith attended her funeral, but likes to focus on another memory, of the day Christen left Central State.
“She was happy, just giggling,” Smith said. “Rocking back and forth, back and forth, giggling.”
Rethinking state hospitals
Georgia has promised to move all people with developmental disabilities out of state psychiatric hospitals by June 30, 2018 – three years after its original deadline for completing an overhaul of how it treats disabled and mentally ill people.
The transfers to community-based facilities, such as group homes, began in response to a federal investigation, which found that conditions in the state’s seven psychiatric hospitals violated residents’ civil rights.
The U.S. Department of Investigation opened its investigation after The Atlanta Journal-Constitution reported on the deaths of more than 100 state hospital patients from abuse, neglect or poor medical care.
As part of a consent agreement with the federal government, signed in 2010, Georgia closed two state hospitals, in Rome and Thomasville, and shifted more services to short-term treatment facilities.
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