A resident at one of Blossom Philadelphia's group homes for adults with intellectual and developmental disabilities died on New Year's Eve after being given a slice of pizza the day before even though he was on a doctor-ordered diet of pureed food only.
The 60-year-old man, who had cerebral palsy and was a Blossom client for 37 years, choked and coughed so hard that he went into cardiac arrest. He died Sunday evening at Pennsylvania Hospital.
Advocates are appalled that the man perished from negligent care in a facility that was under special state supervision since officials revoked Blossom's license to operate the residences on Oct. 24.
"This is beyond tragic. This man did not have to die, " said Kathy Sykes, former director of intellectual disability services in Philadelphia. "This is a colossal failure of responsibility to provide basic care and supervision, a colossal systemic failure to manage a transition, a breach of trust for those who were promised their sons and daughters would be cared for, let alone have an everyday life."
The Pennsylvania Department of Human Services, the primary regulator of the residences run by Blossom (formerly United Cerebral Palsy of Philadelphia), confirmed the death but gave few facts.
"We can confirm that an individual living in one of the Blossom homes has passed away and the department is investigating. Our thoughts and condolences go out to the individual's family and loved ones," a department spokeswoman said by email. "The department is unable to comment further on a specific investigation while it is in process."
The primary investigator of the incident, which occurred in one of Blossom's South Philadelphia residences, is employed by the Philadelphia Department of Behavioral Health and Intellectual Disability Services, which declined to comment.
The state accused Blossom of "gross incompetence" in October and revoked the nonprofit agency's license to operate its 31 community homes with 89 residents. State inspectors found that Blossom failed repeatedly to make repairs, used untrained staff, failed to administer medications, and missed medical appointments. The population included 18 former residents of Chester County's Pennhurst State School and Hospital, which closed 30 years ago.
Relatives said that conditions at Blossom had deteriorated since new management took over starting in 2014, but the problems worsened in July when Blossom laid off its residential staff and hired an outside firm, Integrity Workforce Solutions LLC, an arm of Staffing Plus Inc. in Haverford, to provide workers for the houses. That led to a revolving door of workers going into the houses who did not know the residents and, in many cases, were not fully trained to do their jobs, relatives said.
After Blossom's board decided during Thanksgiving week to leave the residential services business, the Human Services Department picked four providers to take over. On Friday, Barber National Institute is scheduled to take over the South Philadelphia house where the man choked, along with seven other Blossom facilities. The nonprofit already took over two houses late last week.
JEVS Human Services began operating 10 houses Tuesday night. KenCrest assumed responsibility for eight homes Wednesday. The Salvation Army is scheduled to start running the three remaining homes next week.
Over the holidays, some state human services employees worked in the houses to help with resident care, given the risks of the transition. The department spokeswoman said she did not know if a state employee was present during the choking incident.
Sykes and other experts criticized the state's handling of Blossom, which is overseen by the Human Services Department's Office of Developmental Programs. They said they know of no other cases in which state employees were called on to staff community homes.
Early on, when support coordinators "were writing and voicing specific concerns, the regional office with the county should have been conducting unannounced visits while a written plan of correction was drawn up and monitored," said Marianne Roche, a former mental retardation director for Montgomery County.
"But ODP let it go on too long and get out of hand," she said.