Independent Review Identifies GRC Problems
A 27-page report made public last week details findings of a state-commissioned review and assessment of practices and procedures at the Glenwood Resource Center (GRC).
The independent review of the state-managed facility, which currently serves nearly 200 intellectually disabled residents, was conducted amid a separate Department of Justice (DOJ) investigation into allegations of “harmful” human experiments performed on residents; inadequate medical care and nutrition; needless restraint practices; and incidents that resulted in injury to residents.
According to the independent assessment report, written by Mark Diorio, a mental health expert and independent consultant from Virginia, the review identified multiple problems at the facility, including violations of residents’ rights, excessive use of restraints (that increased threat of injury to both residents and employees), inadequate resident care plans, overuse of psychotropic medications to control resident behavior and an inadequate number of employees to provide the “minimal care” required to serve the GRC population.
At the time of the assessment, Diorio said the GRC employed only 308 of the 416 Residential Treatment Workers needed to provide the minimal care for residents. The shortage of RTWs results in over $3 million annually in mandatory overtime hours, staff burnout, inadequate training and supervision of new employees and a high turnover rate, according to the assessment.
The report cited an overall lack of consistent and effective leadership at the GRC over the past decade. From March 1969 to October 2008, the GRC had only two superintendents – Dr. William Campell and Thomas Hoogestraat. Since Hoogestraat’s retirement in 2008, the GRC has had 10 superintendents, some who were full-time and some on an interim basis.
“Any organization that has this kind of turnover in leadership will typically experience short-and long-term problems with continuity, communication, team process and planning, to name a few issues,” Diorio said. “Overall staff morale suffers, people frequently protect their positions and perceived status, trust issues begin to form, recruitment and retention becomes difficult and teamwork becomes disjointed. The quality of care for both staff and individuals suffers.”
During the review, Diorio said GRC Executive Committee members shared information about long-standing problems on the campus in the areas of teamwork, cooperation, communication and problem solving.
The report noted that in 2004 the GRC reached a settlement agreement with the DOJ requiring improvements be made at the facility due to allegations that residents’ rights had been violated. Improvements were made over the next six years and in 2010, GRC was found to be in substantial compliance with the terms of the agreement. However, Diorio’s review determined sometime after 2010, GRC leadership began undoing some of the changes and reforms that had been put in place, resulting in a decline in care.
Diorio said the review determined that Jerry Rea, who was fired as GRC superintendent in December 2019 after allegations surfaced that he was spearheading human subject experiments and sexual arousal studies involving GRC residents, fostered an “unhealthy work environment.” Members of the GRC Executive Committee described Rea as “controlling and intimidating.” Diorio noted that Executive Committee members said “retaliation and fear” were common during Rea’s tenure and employees were reluctant to challenge or question his policies.
Diorio’s review did not examine the experiment or sexual arousal study allegations.
The DOJ investigation is ongoing.
Speaking at a July 15 town hall meeting in Glenwood, hosted by U.S. Sen. Charles Grassley, interim GRC Superintendent Marsha Edgington said the enivironment on the GRC campus is “stabilizing.”
“We’re moving forward. We’ve had a lot of consultants come in and help us,” she said. “Right now, I’m up to about a 500-page Excel spreadsheet – action steps we’re going to be doing. We’re working with our consultants to work through DOJ – the investigation process.”
Edgington noted that the DOJ investigation was initiated last November.
“There were multiple deaths that kind of brought them in, but the main thing that brought them in this time specifically was allegations of experimentation and research that was going on.
“It sounded very ominous, but it wasn’t what it was reported to be,” she said.