KING 5 Investigates: Abuse of DDA Clients

Published May. 13, 2015

Burned, beaten and locked away: State fails disabled woman

Susannah Frame, KING 5 News

Laura Gholston loves to color, sing Twinkle Twinkle Little Star, watch Mickey Mouse cartoons and count to ten - activities most toddlers enjoy. She greets friends and strangers alike with a giant smile, an easy laugh and a loving hug. No one could miss her delightful, innocent spirit.

But Laura Gholston isn't a child. She's a developmentally disabled 48-year-old. She depends on others to tend to her every need: brushing her teeth, changing her diapers, and safely walking her across a street.

In 2011, after seven years in the care of a state-paid caregiver, Laura was rescued from a filthy home in Tacoma where meth and meth addicts were discovered in the garage. DSHS caseworkers and police found her in a back room on a stained mattress without sheets or covers.

She was caked in her own feces and urine. All of her front teeth were rotted out. And covering her arms and legs were fresh and old wounds: burns from a meth pipe.

The state agency charged with ensuring Laura was safe and healthy while paying for her care – DSHS – had miserably failed this vulnerable adult. The case exposes large gaps in the system set up to protect the most vulnerable adults in the state of Washington – those with developmental disabilities.

Laura's problems with the state began 19 years ago, in 1996. At the age of 29, Laura's mother found her daughter in a terrifying state – Laura had given birth to a baby boy, alone, on a toilet in their home in Spanaway. No one even knew she was pregnant.

Laura and the baby were taken to Madigan Army Medical Center where the baby was found to be perfectly healthy. But clearly, Laura could never have consented to sexual relations. Hospital staff contacted the Department of Social and Health Services (DSHS). A caseworker immediately observed, "There is a real question about the protection afforded Laura Mae in her living environment."

Who was the father? Who had taken advantage of this vulnerable adult?

A DSHS social worker forwarded the case to law enforcement. In the referral the state identified the few males who could have had contact with Laura, which included her mother's boyfriend, although the caseworker wrote, "the mother reports she is always present when (the boyfriend) is in her home."

The social worker's notes indicate an aunt had visited and may have brought male visitors into the house. The only other male with access to Laura was a teenage nephew, LaMarcus Gholston, who lived in the home full-time.

Police designated the case a "possible rape," but after that, it appears there was little to no follow up on the part of police or DSHS.

"What happens (on the part of DSHS)? Nothing," said David P. Moody, Laura Gholston's attorney.

The Pierce County Prosecuting Attorneys office declined to file charges against Gholston for the abuse and neglect of his aunt because the alleged crimes didn't reach the level of a felony. The case was forwarded to municipal court for possible misdemeanor charges, but none was filed.

State-paid caregiver is appointed

Four years later the state let Laura down again. Her mother passed away and Laura was without a caregiver. The job would be a challenging one -– someone would need to meet every one of Laura's needs 24 hours a day.

Who got the job? LaMarcus Gholston, the 19-year-old nephew who'd been identified as one of the males that could have impregnated Laura.

State records show that Gholston was not properly screened before being approved by the state to care for his aunt. Gholston passed a criminal background check, but DSHS did not follow its own policies requiring it to ascertain the applicant's character and suitability to provide around-the-clock care.

If DSHS had pursued additional screening, social workers likely would have found that Gholston had had many run-ins with the law and a conviction for marijuana possession. Records would also have shown his name listed on state records as a potential father of Laura's baby.

"That's a decision that is unfathomable," said Moody. "DSHS itself identified Laura's nephew as a rape suspect. That's in DSHS's own documents and paperwork, it's very clear."

The state claims LaMarcus Gholston was never identified as a rape suspect and in fact, had ruled him out back in 1996.

Starting in 2004, LaMarcus Gholston was on the job as his aunt's state-paid caregiver. He received nearly $95,000 over the seven-year period he served as his aunt's official caregiver. And state records show the money was of utmost importance to Gholston. KING 5 found of the 53 telephone contacts between Gholston and Laura's caseworker over the years, 48 of them were about money. Phone records indicate that none of the calls was about social, medical or psychological services for his aunt.

"He bragged, that Laura was his meal ticket, he didn't have to work. He didn't have to do anything. He just got checks from the state month after month," said Ian Bauer, one of Laura's attorneys.

Red flags

Early on signs emerged that Laura was in a troubled home with her nephew in charge. In 2005 a four- year-old niece told her teacher and a CPS worker that LaMarcus "gets the belt" and uses it on Laura. When the CPS worker asked if LaMarcus hit anyone else with a belt, the child responded – "No, just Laura."

The child also said the police were at their house on a regular basis. "All the time. LaMarcus goes to jail all the time but Mommy doesn't."

After those allegations, no one from DSHS checked on Laura.

"We did not do anything," said DSHS representative Leah Stadjuhar in a deposition.

In 2006, LaMarcus Gholston reported to Laura's DSHS social worker, Beth Rubenstein, that he had a job outside the home installing flooring. That would mean Laura's only certified caregiver was not in a position to care for his aunt's needs at all times, which he was getting paid to do. In a deposition Rubenstein admitted she did no further investigation about LaMarcus's outside job.

"DSHS doesn't even bat an eye. They just keep writing checks to a person who isn't even on scene," said Moody of Rubenstein's failure to investigate.

"I would say it's one of the worst cases I've ever seen, yes," said Carol Hunter, a Spokane-based elder law attorney and investigator appointed by the court to look over Laura's civil lawsuit.

"If someone like that - a caseworker who was so apathetic in a deposition -- was the one coming to her home to evaluate her, really delve into what is going on, all I can think of is: she [Rubenstein] walked in, took a cursory look and walked right back out," said Hunter.

The social worker also looked the other way when LaMarcus Gholston notified her he had not completed his state mandatory caregiver training. By policy, that training is to be completed within 120 days or the caregiver contract is to be terminated.

Instead, the state issued Gholston a certificate for "successfully completing" the course anyway. And they paid him for the training as well - $264 in "training wages" for training he never completed.

After Laura's rescue

State payments to LaMarcus Gholston only stopped after Laura's rescue in 2011. A DSHS investigation found Gholston had neglected and abused his aunt, including routinely burning her with a meth pipe.

On the day KING 5 spent with Laura in April, she only turned serious once, when the reporter asked about a scar on her arm.

"It's a burn, a burn. Marcus Gholston," said Laura.

Police found something else in the squalid home in 2011 - a lock on Laura's door only accessible from the outside.

Laura's attorneys included the allegations of imprisonment in their lawsuit.

"She was locked in that room for hours and hours and hours," said Bauer. "He would lock her up while he went to work. He would lock her up just because he didn't want to deal with her. She was a hassle. She was an impediment to him playing video games."

Systemic breakdown

Laura Gholston's case highlights the lack of safeguards for all developmentally disabled adults in Washington state. Those with state-paid caregivers are essentially on their own. DSHS caseworkers are only required to make one annual pre-scheduled visit. Whereas with children, social workers are obligated to check in every 30 days.

"Laura and other vulnerable adults deserve more," said Katherine Kent, a former DSHS social worker and current attorney with expertise in abuse cases. "We have vulnerable adults who are functioning on the level of children yet, we're treating them vastly different, with no safeguards, no protection, no monitoring," said Kent.

Today Laura is living in an adult family home in the Tacoma area where she's safe and able to be herself -– a child with a big smile and a big heart.

On April 17 Laura's lawsuit was settled with DSHS for $2.5 million. The money will remain in a trust to be used for her care and therapies.

DSHS representatives would not comment on any specifics of this case. A media representative said policies have changed for the better since this case was filed but didn't answer when KING asked for specifics.

The department offered the following written statement:

"The Department of Social and Health Services has agreed to settle a lawsuit resulting from a 10-year-old abuse and neglect case involving a woman with disabilities. As the agency charged with promoting the safety of our state's most vulnerable populations, DSHS always considers it a tragedy when one of our vulnerable citizens is harmed.

"Mistakes were made in this case and DSHS did not ensure this client was safe. DSHS typically agrees to settle lawsuits when we have not completed our work to our standards and to ensure that taxpayer money is well spent and the victims receive the care and services they need going forward."

No one at DSHS was held accountable for their failures in Laura's case.

KING 5 brought the Laura Gholston case to the attention of state Sen. Steve O'Ban (R-Pierce County), chairman of the Senate committee that oversees DSHS. He said he is troubled by the case and that it appears no changes have taken place within the agency in an attempt to prevent a similar situation.

O'Ban said he already has staff working on legislation to be presented in the next session to make some accountability mandatory.

"We have got to minimally in those situations have an automatic review, where there was a breach in policy we have to ask the question, 'Why?' And the supervisor and caseworker have to be disciplined. It's just common sense. So that is what I hope to do," said O'Ban.

View the video report and read the full story:


Millions in payouts fail to improve care for vulnerable adults

A record-setting verdict against the state of Washington 15 years ago was expected to produce big changes in the system that cares for developmentally disabled adults. The $17.8 million in damages and additional $1 million in legal costs awarded to three developmentally disabled men were seen as a stinging rebuke to Washington's Department of Social and Health Services (DSHS).

But in the decade-and-a-half since, DSHS has paid more than $30 million in new jury verdicts and settlement agreements for lawsuits filed on behalf of abused and neglected developmentally disabled adults. Each of the lawsuits exposed problems in how DSHS cares for vulnerable adults, yet the KING 5 Investigators found few improvements have been made, raising serious questions about the state's commitment to fixing a broken system.

In the 2000 lawsuit, the state's care for three developmentally disabled adults was found to be woefully inadequate, resulting the awarding of the largest jury verdict against the state in Washington's history. After a six-week trial in Pierce County Superior Court, the jury concluded that the victims -- Eric Busch, Damon Beckman and Bill Coalter -- suffered physical and sexual abuse at their state-licensed home in Bremerton and that state caseworkers ignored the signs of abuse. The jury also found the state shouldn't have licensed the men's caregiver in the first place, as he had been accused previously of abusing a disabled man.

What should have been a wake-up call to DSHS to improve its care for these vulnerable adults went largely unheeded.

"One would think that would have come to the attention of DSHS, to the governor, to the attorney general – right then and there changes would be made. Well, they weren't," said plaintiff attorney David. P. Moody. "I see words, we see changes in administrations and yet the problems continue and I would argue based on what I see, the problem's getting worse."

"It makes me sad that it's still that way," said Joe Busch, father of victim Eric Busch, who is now 41-years-old. On a recent day a KING 5 crew visited the Busch's Port Orchard home and watched as Eric enjoyed riding trikes and playing on a swing set with his dad.

"He's a little child. He depends on us for everything. He can't take care of himself. They may have different talents, but they're as good as you and I and they deserve what we have and even better because they can't take care of themselves," Joe Busch said.

In the years since Eric Busch and the two other victims won their case, more developmentally disabled adults have found themselves abused and neglected. All of the cases have a similar pattern: The state authorized payment to an inappropriate caregiver and then case managers failed to heed warnings of abuse.

Steps DSHS could have taken to protect these vulnerable adults were never taken. Advocates for developmentally disabled adults highlighted the missed opportunities:


To this day, caregivers hired by the state are only required to fill out a simple application, pass a background check and go through a basic training program. DSHS does not conduct a home study during the screening process, nor is a background check done on other people living in the caregiver's home. Also, there is no policy mandating that screeners contact law enforcement about the applicant.


Case managers are only required to visit their developmentally disabled adult clients once a year, whereas in the foster care system case workers visit child clients once a month. The state does not require case workers to make unannounced visits to a caregiver's home.


There is no requirement for a case manager to meet with his or her supervisor to review a client's case. In the child foster care system, by comparison, case workers meet monthly with a supervisor to review each child's case.

Caseworker-to-client ratio:

For case manager's working with developmentally disabled adults, the ratio of case managers to clients is 1 to more than 100. In the foster care system, that ration is 1 to 18.


DSHS imposes no requirements for investigation, review or discipline in cases where mistakes lead to a developmentally disabled client suffering abuse or neglect.

State Sen. Steve O'Ban (R-Pierce Co.), chair of the Senate Human Services, Mental Health and Housing Committee, said he wants the legislature to take action.

"If you're an organization that makes a mistake, you should be the first one to examine that mistake and come up with a new policy and make sure it doesn't happen again. It just doesn't seem like we have that here," said O'Ban.

DSHS response

The top executive of DSHS, Sec. Kevin Quigley, defended his agency. He said they're putting more resources into programs for the vulnerable than ever before. As an example he said care providers must go through more thorough background checks now. Quigley said they're working on better responses to allegations of abuse.

"The way the system works, when the doors are locked and the curtains are pulled we can't protect every one of these clients. What we need to do is have a system that's effective at responding when we hear allegations of abuse," said Quigley.

Laura Gholston's story

The lack of improved safeguards led to Laura Gholston of Tacoma becoming a victim as well. At 48 years old she operates at the level of a toddler. In April she won a $2.5 million settlement against DSHS for mishandling her case. The mistakes were similar to those in the Busch, Beckman and Coalter case 15 years earlier: The state authorized payment for a caregiver, her teenage nephew, who should have been flagged as inappropriate for the job. Once hired, DSHS employees failed to follow up on warnings of abuse.

After seven years of paying Gholston's nephew to take care of his aunt's every need, police and DSHS employees rescued Laura in 2011. They found her in a filthy home in poor health. She was exceptionally thin and all of her front teeth had rotted out. Laura was in a back, locked room on a stained mattress without sheets or blankets. She was covered in urine, feces and burns. A state investigation found the nephew had repeatedly burned Laura with a hot meth pipe to keep her in line.

Gholston's state case manager testified in a deposition that she visited her client every year as per policy, but didn't notice the filth, rotting teeth or burns.

"It just seems like there is a systemic breakdown when it comes to basic employment supervision that we would expect from most employers and certainly from those who are caring for the most vulnerable in our society," said Sen. O'Ban.

When KING 5 first approached DSHS about the Gholston settlement, a spokesperson said it was an old case and that policies had improved since the time she was under her nephew's state-paid care (2004-2011). But DSHS was unable to detail the improved policies.

After the reporters asked three times to provide specifics, a DSHS spokesperson sent an email referring KING 5 to the Service Employees International Union -- the union representing caregivers.

"We would suggest that you contact officials of SEIU, which has been instrumental in advocating for initiatives since at least 2008 for direct care and long-term care providers. These initiatives have more than doubled the number of training hours needed, strengthened the state and federal background check system and exams and skills testing for long-term care workers. These are all improvements that have benefited DDA clients served by Individual Providers," the DSHS spokesperson wrote.

That response drew an angry reaction from attorney David P. Moody, who represented Gholston.

"Sending you to the union is preposterous. DSHS needs to look itself in the mirror and ask itself why time and time and time again it's ignoring warnings of abuse and not holding its own employees accountable," said Moody.

The SEIU said they have improved their training standards for caregivers, but the state needs to do more to protect clients from abuse and neglect.

"The oversight of the Individual Provider program is the domain of the state DSHS. Given the existing structure of oversight for individuals with development disabilities (one visit per year according to your report) it seems possible that another case of abuse could occur with such infrequent oversight," said Adam Glickman, an SEIU officer. "If the public wants to ensure that oversight is improved, it seems like it would be wise to ensure that DSHS was provided adequate resources by the legislature to increase the frequency of case worker visits to vulnerable adults like Laura Gholston. A woman with the intellectual capacity of a three year old should have no less case management than a child (every 30 days) who has no ability to protect themselves against those who would do them harm."

Sue Elliott, executive director of Arc of Washington, a group that advocates for people with developmental and intellectual disabilities, also panned DSHS's response.

"I think talking to the union would be good if you were doing a story about how wages have increased for providers. I don't that that is the answer I would be looking for if I were asking, 'How has DSHS improved the lives of people?' That isn't an answer I would accept," Elliott said.

Washington lags behind nation

KING 5 also found that Washington state ranks near the bottom nationally when it comes to providing resources for the developmentally disabled. A respected annual report by researchers at the University of Colorado, "The State of the States in Intellectual and Developmental Disabilities," ranked Washington 45 out of 50 in "fiscal effort" for the developmentally disabled population. "Fiscal effort" is defined as spending on services per $1,000 in aggregate statewide personal income. Other states that scored poorly included Alabama and Florida. Mississippi and Missouri ranked at the top.

"I'm embarrassed when some of the southern states, when you think they don't support people well, that they do better than our state does and I think it's an embarrassment. I can never figure out why we're not willing to invest more in people that are not able to care for themselves," said Elliott.

According to DSHS's Developmental Disabilities Administration (DDA), an estimated 81,000 people in Washington state have a developmental disability. Of those, 26,610 receive at least one state-paid service from DDA, while 14,126 people with a developmental disability are on a waiting list and receive no services whatsoever from DDA.

In his 2015-17 operating budget, Gov. Jay Inslee (D) proposed cutting funds to expand services to more developmentally disabled adults, though Inslee's budget proposed increasing the pay for caregivers.

Advocates and parents hope citizens of Washington will demand better from the state - more respect and protection for this special population.

"They're still human beings and they have a lot of love in them. He's given me more than I've given him," said Joe Busch.

Legislative action

After KING 5 aired the story of Laura Gholston in April, Sen. O'Ban pledged to investigate. On May 7 three committees -- the Senate Human Services Committee, chaired by O'Ban; the Senate Health Care Committee, chaired by Sen. Randi Becker (R-Eatonville); and the House Early Learning and Human Services Committee, chaired by Rep. Ruth Kagi (D-Seattle) -- held a work session in Olympia to develop ideas for legislation to ensure cases like Gholston's don't happen again. Legislation mandating fixes could come in next year's legislative session.

In a presentation to the committees, a panel of advocates for the developmentally and intellectually disabled population noted: "Protecting individuals who are at-risk is a priority of Washington State as detailed in Article XIII of the State Constitution. The Gholston case highlights a number of problems in our state system which must be addressed. Abuse and neglect are more prevalent when people are isolated."

Read the groups' recommendations to the committees. 

View the video report and read the full story:  

Follow Susannah Frame on Twitter -- @SFrameK5.

This story aired originally on May 12, 2015.