TRAVERSE CITY — Trouble brewed on the buses for months, but it took a terrible beating of a seriously disabled woman for officials to take serious notice.
An Aug. 22, 2011, assault on a local public bus triggered a widespread investigation and report that faulted Northern Lakes Community Mental Health for failing to protect the woman and 66 other CMH clients during their rides.
Jonathan Bennett, the man who probed the assaults and wrote the report, subsequently was fired from his job as Northern Lakes' director of the Office of Recipient Rights. He contends his ouster came in retaliation for his findings.
Bennett recently filed a whistleblower lawsuit against Northern Lakes, his former employer.
"I loved my work and it's a real loss," said Bennett, who was fired in October after 15 years on the job.
Greg Paffhouse, Northern Lakes Community Mental Health's chief executive officer, refuted Bennett's allegations.
"I still like Jon as a person," Paffhouse said. "But I became aware of how broad and how deep the conflict was between him and a large number of people. The ability to do our jobs was being compromised and would be increasingly compromised."
Bennett received news of the August 2011 assault a month later, on Sept. 23, when an official from Grand Traverse Industries told him a woman was "beaten horrifically" by another Northern Lakes client on a Bay Area Transportation Authority bus.
Northern Lakes pays BATA to transport developmentally disabled clients back and forth to GTI from where they live, usually in adult foster care homes. GTI provides day programs, training and jobs at two different sites.
A BATA surveillance tape showed that over a 90-minute bus ride, the woman was choked, grabbed, and hit more than 100 times. The bus driver appeared not to notice.
The woman, who already lost one arm in a prior accident, was helpless. She couldn't cry for help or report the attack because of her profound physical and mental limitations. A GTI staff member noticed the woman's injuries when changing her diaper, Bennett said.
The woman's service plan — which lists a client's treatment and support needs — required she have supervision "at all times." Yet a bus aide — effectively a chaperone provided by Northern Lakes — had never been assigned to her.
Northern Lakes staff met with the woman's family after the attack; she was removed from the bus at once, and the offender was banned from BATA on Aug. 24.
Bennett suspected more clients were at risk and deepened his investigation. He found about two dozen incidents on BATA buses over 18 months, including disrobing, disconnecting bus wires, fondling, and throwing objects.
In a January 2011 incident, one client broke into a bus biohazard clean-up kit, ingested cleaner and threw up for 30 minutes. Other clients were medically fragile, according to Bennett's Dec. 27 report.
In all, 67 of the 154 bus riders already had service plans that required supervision; none had bus aides.
'Not my responsibility?'
Bennett raised warning flags soon after he learned of the August 2011 incident. He consulted with Northern Lakes staff about finding an immediate remedy.
Northern Lakes case workers already knew which clients needed supervision. Bennett maintains it would have taken little effort to add bus supervision to their plans, a required step to get funding to pay aides.
When Bennett talked to one manager on Oct. 10, 2011, about modifying clients' service plans, she said, "It will take time "¦ it's not my responsibility."
"I asked her to discuss this and she closed the door of her office," Bennett wrote.
Paffhouse insisted staff members took Bennett's concerns seriously. They had to identify previous incidents and assess clients' levels of risk.
"Once there was the awareness, we put supervisors and managers on the bus the next day," Paffhouse said.
Bill Rossbach, the step-father of a 32-year-old Northern Lakes client, said the facts show "it just wasn't important enough" to move faster.
Bennett's lawsuit alleged "foot dragging," even after he presented Paffhouse with written recommendations on Nov. 10, 2011. Shortly afterward, he went to the state Department of Human Services' Adult Protective Services to trigger action.
On Nov. 29, 2011, DHS officials met with the two men and Northern Lake's Chief Operating Officer Terri Kelty, and asked why there was no action. They warned Paffhouse that unless he took immediate steps, DHS would tell guardians the clients were at risk of harm, Bennett said.
As a result, staff rode buses the very next day, followed by aides thereafter.
Bus troubles continued during months of the alleged delayed action. October 2011 saw a client remove his clothes, one client yelling and crying, and another touching a client in a sexual manner.
In November, a client repeatedly kicked another on three separate incidents. The assaultive man in the August incident returned to the bus within a month because Northern Lakes officials failed to tell his provider he'd been suspended from the bus, Bennett reported.
Rossbach wonders why Northern Lakes knew for years that some clients were vulnerable and others potentially violent, but didn't protect them. Rossbach's wife said she assumed BATA bus drivers supervised Northern Lakes clients.
A Northern Lakes case worker told Bennett the same thing.
"We had people ride the BATA buses for a long time and with a positive history," Paffhouse said.
But BATA staff told Bennett that agency employees do not and cannot provide supervision. Kelly Yaroch, BATA's director of human resources, said she doesn't know why BATA didn't address the series of problems with Northern Lakes earlier, but aides have since resolved a number of concerns.
Bennett's BATA bus report spurred months of acrimonious meetings, a staff petition that targeted Bennett, a consultant study, and state investigations.
By law, Bennett is supposed to conduct investigations unimpeded and without retaliation in order to effectively protect client rights.
The consultants, hired by Paffhouse, issued a report that reflected a deep rift between staff, service providers and Bennett. A large majority of the sampled staff members said Bennett was "difficult," and they no longer sought him out for advice or counsel. The consultant recommended firing Bennett.
The state Department of Community Health countered with a report that said the consultants' methodology was flawed and failed to determine if staff statements were true.
Judy Barrett, a parent and guardian of a client, said the consultants interviewed her, but she didn't see her comments in the report. She has high regard for Bennett, who she calls a "guardian angel" for herself and her adult daughter.
In a separate matter, the state ruled in favor of Rossbach's complaint that Paffhouse was guilty of inadequately disciplining staff who put clients at risk of harm. The state did not find that Paffhouse was personally responsible for the alleged delay and will issue a re-investigation of that question this month.
In October 2012, the Northern Lakes board sanctioned Paffhouse and required he put a warning in his file indicating possible termination if a mental health code violation occurred again.
The day after the sanction, Paffhouse fired Bennett.
Two months later, the state issued a long-awaited report that concluded a lengthy pattern of Northern Lakes staff non-cooperation, and retaliation and harassment against Bennett. There also was extensive documentation of provider and staff complaints against Bennett, but Paffhouse did little to investigate them, the report said.
The Northern Lakes board contributed to problems by failing to hold Paffhouse accountable to address personnel problems, a shortcoming that fostered an environment of "open defiance" against Bennett.
The "impartial" consultants' report, it said, hurt Bennett by empowering staff to object to his actions.
Some wonder if the state report would have or should have saved Bennett's job.
Candyce Vandermoere, a board advisory committee member and parent of a CMH client, said there was "no good solution" to what she described as a messy situation, but something had to be done. She faulted both sides for letting the situation deteriorate.
"Jon as director was outstanding at his job," she said. "Unfortunately, this was an in-house thing that developed over many years and was just never handled appropriately from the get-go."