Senator Eliot Shapleigh - El Paso, Texas

A resident stands outside Agape Place, a licensed care home in Oak Cliff. Human feces caked the yard and only one bathroom worked when city code inspectors visited in March. The director said problems are being fixed. (Barbara Davidson/DMN)

Hundreds of boarding homes across Dallas warehouse the elderly, the disabled and the mentally ill in privatized bedlam. They are what the head of the region's mental health system flatly calls "mental health slums."

City officials believe at least 350 unlicensed, unregulated board and care homes house 2,500 people across Dallas – probably more.

"Pretty much, you can open up a boarding home anywhere you want to, stuff as many people in there as you can, keep them at 85 degrees or worse in the summer and 50 degrees in the winter. You can nearly feed them dog food and get away with it," said one veteran caseworker in North Texas' privatized mental health system.

"So many of the residents are clearly psychotic. We have clients who think they're God," the worker said. "Who's going to believe them when they say they're being mistreated or ripped off?"

Dallas' problems aren't unique, but official inaction here has made them worse.

The city and the state haven't closed troubled homes, and state regulators have shown little enthusiasm for pursuing unlicensed ones. County prosecutors have refused to take homes to court for violating state laws. The Social Security Administration has allowed home operators to control residents' disability checks, and that has led to abuse.

Dallas County pays hundreds of thousands of dollars a year to put people in some of these unlicensed facilities. And officials say it's all the county can afford as it tries to help the indigent and homeless.

There is little money for treatment – let alone housing programs – in a state ranked 49th in funding mental health programs, advocates say. So mentally ill people suffer and taxpayers get the tab for constant police and fire calls, jail stints and emergency treatment at Parkland and other hospitals.

Officials, mental health care providers and advocates acknowledge they've come to view the homes as a grim necessity. They share the belief that living in a bad one is better than living under a bridge.

That's akin to child-abuse investigators saying, "Oh, they only beat and starved the child but didn't kill it," said Texas A&M Regents professor Catherine Hawes, a national expert in long-term care regulation.

"It is a failure of government at every level – a failure of the mental health system that is so committed to moving people to 'the least restrictive environment' that it will tolerate them becoming homeless or living in conditions the Humane Society would not accept for a dog," she said.

"It is a failure of the regulatory system to ensure that all places housing vulnerable adults be licensed and meet minimum standards," she said. "It is a monumental failure of the judicial system not to protect these vulnerable adults. And it is a failure of our society that we allow this to occur."

The city formed a boarding home task force last fall. "The problem is a lot bigger than we first imagined. ... Every time we look, it seems to grow," said assistant city manager Charles Daniels, head of the task force.

The task force will brief the City Council on Wednesday on plans for better protecting neighborhoods and boarding home residents. "I know a lot of people do look at them as throwaway people. It is hard to get people to care," Mr. Daniels said. "But these are residents of the city of Dallas. The city has an obligation to protect them."

Troubled residents

The names of Dallas' board and care homes evoke hope and stability and family for people who have lost all of those things. Their residents are ex-cons, substance abusers, the chronically mentally ill, the mentally retarded and the elderly poor. Some are comfortable. Others are faded apartments, dilapidated nursing homes or flophouses indistinguishable from crack houses.

Some operators are good people trying to help the disadvantaged. But others are predators – as many as half of those in business, some officials and advocates say. Some drive luxury cars, while their residents trade $623 monthly Social Security disability checks for Dickensian squalor and a diet of bologna sandwiches, Ramen noodles and food-pantry handouts. Some have run unlicensed homes for years despite court orders and promises to quit.

Michelle Cotten may be a typical resident – 55, bipolar and unable to work or live on her own since her 20s. She said trying a care home seemed attractive when her mental health caseworker offered her a home list. Her mother, Ouida Banks, 92, said the caseworker didn't mention until later that the first home Ms. Cotten chose had long been known as a problem.

Ms. Cotten was in and out of three homes. The first was a place where she once went without heat in the winter and sometimes didn't eat until midnight – that's when someone brought food. No one ever told her or her mother that her second care home was being pursued by the state for operating illegally. Her last care home was a bug-ridden place where she fell asleep each night staring at a gaping hole in the ceiling. An air-conditioning duct had fallen through it, onto her bed's previous occupant, she said. "She had to go to the hospital," she said.

Another resident turned tricks when she wasn't feeling too ill from HIV, she said. The back stairs were so rickety that Ms. Cotten fell walking down them to smoke. She broke her back. "You might think you want my life," she said, "but you'd get tired of it."

"These group homes, they kind of dwell on mentally ill people," added her mother, a retired Dallas County court employee. "They can treat 'em any kind of way."

Nowhere else to turn

The dependence of so many mentally ill residents on boarding homes is rooted in changes in the mental health system. With new medications and deinstitutionalization in the 1970s, Texas began moving the severely mentally ill from state hospitals to outpatient care. Terrell State Hospital has since shrunk from more 2,500 beds to 316. The average stay is now about three weeks.

The region's mental health programs also have undergone a sea change since the '90s, shifting to a managed-care program. Although many advocates and officials say community treatment has improved, state funding hasn't kept up with demand. Funding for the few supportive housing programs for the chronically mentally ill has also been cut.

Caseworkers and advocates say profoundly disturbed, heavily medicated patients are often discharged from mental hospitals when they're barely stable. Many have no homes or families to return to. Caseworkers have to find someplace to put them and turn in desperation to unlicensed board and care homes.

"Everybody gets in a high-pressure situation," said Myrl Humphrey, a vice president at ABC Behavioral Health, a mental health care provider in the North Texas system. "We've got to get them out of there [the state hospital]. That's how they end up dumping them in those places."

The region's largest mental health care provider, Metrocare Services, maintains a boarding-house list with about 90 Dallas homes – only 12 of which are licensed.

Dr. James Baker, Metrocare's executive director, said his staffers aren't supposed to recommend unlicensed homes but know most clients can't afford any that are. So caseworkers hand the boarding-home list to clients and "follow them where they choose."

That's a sidestep around state law. Mental health care providers jeopardize state contracts and funding if they refer clients to illegal, unlicensed homes.

Dr. Baker said decent housing is crucial to treatment, and not spending money on that and other services for the mentally ill means more expensive emergency treatment and jail costs. "You get to the point that you decide you're going to do the best you can with what you've been given," he said. "And what we're given isn't adequate."

Mentally ill offenders in the justice system are also steered to unlicensed homes. "It's epidemic level," said Margaret Johnson, a court-appointed lawyer for special-needs offenders. She cited a recent case as typical: A bipolar client was paroled to a dingy, two-bedroom boarding home with eight other residents. He fled and ended up back in jail after being hit with a pipe for complaining about other residents smoking crack.

Regional mental health chief Ed Miles said mental health, justice and social agencies have pointed fingers and tried to shift costs instead of tackling the issue together. "You have agencies arguing about who is responsible and who can back it up with funding," he said. "There's been, really, a dramatic lack of coordination."

Disability checks

Making things worse is boarding-home residents' poverty. Many survive on $623 monthly Social Security disability checks. Even that pittance makes them targets for abuse.

"Boarding homes will go to homeless shelters and round people up," said Erroll Willis, a Veterans Affairs staffer who works with veterans who can't manage their own finances. "The boarding homes have people handing out cards, saying, 'If you need assistance getting your [disability check], we'll do it.' "

Social Security allows disability recipients who can't manage finances to have monthly checks sent to a person they designate as "representative payee." Boarding home operators often demand to be named residents' payee, and mental health advocates say that's not always unreasonable. Many residents will blow any money they get on drugs and alcohol.

Unlicensed Dallas homes that take the poorest, most troubled residents charge $500 to $600 a month, promising allowances from what's left from disability checks. In contrast, a recent survey found the average monthly charge for licensed assisted living in Dallas was about $2,500.

Some owners profit by crowding in disability recipients and feeding them poorly, advocates and officials say.

Ms. Banks, the retired Dallas County worker, said that happened to her daughter, Michelle Cotten.

One unlicensed Dallas home that Ms. Cotten chose from her mental-health provider's list hired teenagers and eventually quit buying food or utilities. They said the operator abandoned her daughter and others, and Ms. Banks called police. In a March 2005 report, Dallas police described finding Ms. Cotten and two other confused residents in a home emptied of furniture.

Ms. Banks said another home operator recruited her daughter and, as soon as she moved in, made her file papers replacing Ms. Banks as her daughter's representative payee. Ms. Banks said she got her daughter out, but spent months getting the boarding-home owner removed as payee. She said she never recovered several of her daughter's disability checks.

"I do try to screen places," Ms. Banks said. "There's a lot of things the state or somebody really needs to know about."

States are supposed to report substandard homes to the Social Security Administration, so they can be screened when disability recipients request payees. States also have had to certify annually since 1976 that no federal disability recipients are in substandard board and care homes. Critics have long said those requirements lack teeth.

Despite frequent complaints from disability recipients, Dallas officials and advocates say, they seldom hear of payees punished for mishandling money. Police also get reports but say they can do little.

"We get complaints all the time from the residents who are out panhandling. They say they're hungry. They talk about not being fed enough – that's constant," said Southwest patrol division Lt. Kimberly Stratman. "People in these homes are potential victims – not criminals."

Social Security's Dallas regional office referred questions to media representatives who did not return calls over more than a month.

Home inspections falling

Regulation of board and care homes in Dallas falls through city and state cracks. Texas law requires facilities to get assisted-living licenses if they help clients with bathing and eating or if they dispense medication and house four or more residents unrelated to the owner.

While the number of nursing homes in Texas – and the number of people in them – has fallen over the last nine years, the number of licensed assisted-living facilities has soared. For every state licensed home, regulators recently estimated, there may be two unlicensed ones.

As the industry has grown, Texas regulatory efforts have shrunk. State reports indicate that inspections of licensed assisted-living facilities and unlicensed homes have dropped 14 percent between fiscal 2002 and fiscal 2006. The state has rarely used its regulatory powers to close licensed homes or put in outside supervision. And policing of unlicensed homes has dipped since regulation moved in 2004 to the Department of Aging and Disability Services.

In Dallas County, DADS' unlicensed home inspections fell 30 percent between fiscal 2002 and 2006. In the fiscal year ending last September, DADS surveyors made 42 visits to 33 unlicensed assisted-living homes. They found in 18 of those visits that homes violated state law.

The Dallas County district attorney's office also has declined to take DADS case referrals for at least eight years, a district attorney's office spokesman said. In contrast, Harris County's district attorney regularly gets court orders fining or closing bad homes. Houston's DADS officials are also more likely to fine homes and go after unlicensed ones than their Dallas counterparts.

Cecilia Fedorov, a DADS spokeswoman, cautioned against comparisons between cities because regulatory decisions are made "case by case." She added that DADS inspectors have no legal authority to go looking for unlicensed homes unless they get complaints.

When investigators do go to unlicensed care homes, records indicate, they focus on whether the operators are doling out medications. When operators and staff say they don't, and there's no blatant evidence otherwise, cases are closed. If investigators do find violations, records indicate the agency often opts to send a warning letter.

When inspectors identify violators, licensed or unlicensed, the agency must consider "our jurisdiction, what we have the ability to do, and the circumstances surrounding each individual case," Ms. Fedorov said.

"While our role is enforcement, we must weigh the overall environment – to include a lack of affordable housing, limited resources for MHMR [mental health and mental retardation programs], the availability of appropriate licensed placements," she said.

The agency will close a facility only if it can find licensed homes that will accept the residents involved and charge what they can afford. Otherwise, she said, "we would be effectively putting those residents on the street or placing them in another facility which could be unlicensed."

A recent internal memo prepared by DADS on the issue of expanding state regulation of unlicensed homes was more blunt. Though DADS does have authority to close a home without court action if it is endangering residents, the December 2006 memo stated, it would then "be responsible for relocating the residents."

Dr. Hawes of Texas A&M said that, unlike Texas, most states pay supplements for Social Security disability recipients in licensed homes, "so vulnerable, disabled and poor residents will not face this choice of homelessness or housing in an unlicensed facility." Only licensed homes get the supplements, she said, giving homes incentive to get licensed.

She noted that a study she led in the mid-'90s for the federal government found Texas was among five states "with the weakest regulatory systems and the highest number of unlicensed homes." She said she still hears DADS officials voice concerns about the current regulatory system.

Criticism of DADS

People who keep an eye on care homes say DADS doesn't seem interested in getting a grip on unlicensed homes. Licensed industry representatives say that they regularly raise concerns about the homes to agency officials, only to be told they aren't a problem.

State Rep. Jose Menendez, D-San Antonio, said DADS officials have fought his bill requiring licensing and inspection of every facility providing meals, shopping, transportation or other services to three or more unrelated patients. Violators could face criminal fines of $1,000 for a first offense and $500 for additional ones, plus civil penalties. And the fines would go to regulatory efforts.

The state agency initially said the added regulation would cost $42 million in its first two years – a potential bill-killer for fiscal conservatives. Mr. Menendez thought DADS officials agreed that tinkering would drop the price. But DADS then upped its cost estimate to $50 million.

The agency's representatives have warned that DADS might have to regulate convents, motels and fraternity houses. Last week, DADS and Texas Adult Protective Services officials released an 18-point critique, warning that the bill could hurt group homes for the mentally retarded and lead to more elder abuse, neglect and exploitation. Among the downsides noted by the agencies: The bill would make local and state agencies stop referring people to unlicensed homes.

Dr. Hawes, the Texas A&M professor, said most states require licensing for any home housing two or more unrelated individuals – and don't have a problem with over-regulating other businesses.

Mr. Menendez said he is baffled by the agency's full-court press. "My level of frustration is through the roof," he said. "What's the potential cost to the state if we don't do something? What's the potential harm for people in these homes and the people living next to them if we don't try to get this under control?"

In El Paso, a probate judge saw the results of a lack of regulation. The judge, Max Higgs, said he was disturbed by mental-health agency referrals of vulnerable people to filthy, unlicensed homes that fed them rotten food and pocketed their Social Security. He appointed a lawyer to investigate. But the attorney general's office went to an appeals court, argued that the judge lacked jurisdiction and got the hearings halted.

Now retired, Mr. Higgs remains incredulous that the state's priority seems to be "stopping people from knowing how bad the situation really is."

In Dallas, officials with the Veterans Affairs have regularly warned DADS about problem homes and nothing happens, said Gloria Johnson, who oversees the VA's placement of veterans in licensed assisted-living homes. VA representatives visit the 43 North Texas homes in their program at least monthly to ensure all meet VA care requirements.

She recalled one state-licensed operator showing her a filthy Oak Cliff home with inadequate food and linens and a weedy yard last August. The operator was irate when rejected by the VA. Others applying to get VA contacts have admitted feeding residents only oatmeal, bologna and beans. One had a building so shoddy, she said, that VA staffers couldn't believe it passed state inspection.

"There are no consequences for bad care," said Mr. Willis, the VA field examiner who has visited homes all over Dallas since 2000. He said he has reported licensed homes for lack of food or heat and allowing residents to go so long without bathing that anyone walking in their facilities could smell them. All he can do, he said, is encourage veterans to move and refuse to pay homes that don't meet VA standards.

The severity of Dallas' boarding home problems appalled Dr. Miles, director of the North Texas Behavioral Health Authority. Last fall, he made an emotional presentation to his board. He also called DADS. "They read their policy to me," he said. "What it amounts to is there's nobody supervising these places."

He said he saw care-home issues as head of Florida's mental health system. But Florida counties and cities have more regulatory powers, he said. "At least you could call and complain and the problem would be looked at."

Dr. Miles said he'd like Dallas to do more but knows the city is "overwhelmed. It's crazy to me to expect the city to be able to regulate these places alone."

Ordinances not enforced

Dallas does have boarding home ordinances that the city hasn't enforced. The homes are required to get inspections and certificates of occupancy. But some don't bother. When caught, some operators have held off inspectors by claiming to be exempt from city oversight, records show.

City statutes confuse matters by terming the homes everything from group homes to boarding houses, rehab centers and residential hotels. The names determine how the city can restrict them. A U.S. Supreme Court ruling limits regulation of homes with eight or fewer disabled residents; restrictions on those homes must cover all property owners.

Records show homes sometimes go years without repairing violations. Mr. Daniels, the assistant city manager, said inaction has allowed the city's boarding home problem to spread. "It's like fire ants," he said.

The City Council passed a boarding home ordinance in 1998, prompted by state legislation on assisted living. The ordinance requires businesses providing personal care, room and board to four or more people to get state licenses and meet size and safety standards. Violators can face city fines and referrals to state regulators. If asked by state regulators, city attorneys can seek court injunctions and closure orders.

But none of that happened. "There's no valid reason why," said Mr. Daniels.

Complaints about board and care homes in Oak Cliff and East Dallas led to a city task force in 2003. The city's crisis management team gathered home operators, city staff and mental health experts in hopes of getting homes to meet standards voluntarily.

The City Council passed an ordinance requiring boarding homes to register annually and undergo regular inspections, along with multifamily properties such as apartments. Code enforcement began apartment registration and inspections but never got to boarding homes. Soon after, the task force folded.

That panel's chair, city crisis intervention manager Dave Hogan, said other priorities intervened and no one could answer a lingering conundrum: Would enforcement just add to Dallas' homeless problem?

So his staff continued social-work triage, moving residents when they discover horrific conditions and cajoling owners of better places to take people, Mr. Hogan said. "We sometimes find ourselves negotiating and looking the other way."

Another task force

Adam McGough, an assistant city attorney, began exploring the issue in early 2006, prompted by citizen complaints. He found boarding homes with sewage leaks, eight or 10 beds to a room, and beds in closets.

His findings, other complaints and mental-health community concerns prompted City Manager Mary Suhm to start a new task force last fall. The city named a boarding home code inspector in February, and county representatives have joined task force meetings.

The task force will brief the council next week about a new boarding house team including police, code and fire inspectors and social workers. They'll also discuss funding and housing solutions.

Mr. McGough notes that some boarding homes have already done repairs, moved or closed. He and others worry, though, about unintended consequences. After one flophouse hotel agreed late last year to quit housing permanent tenants, he notes, a mentally ill resident told to move set fire to her room.

Bottom line, Mr. Daniels said: The city needs help. "Is there going to be some sort of safety net, or are we going to be the ones having to provide care?" he said. "It's important that we get some additional assistance from the state and the federal government."

Mental health officials say they've seen too many past efforts to be too hopeful. "We're fearful of doing anything, the problem is so huge," said Melodie Shatzer, director of ABC Behavioral Health. "It's going to take money, and it's going to take the collective will of the community."

State commitment is a must, she said. "Until we make a decision that all of these facilities have got to be licensed, monitored regularly and adequately funded, we're going to continue to have this problem."