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He raises his hand and says, “Five minutes,” as his caregiver waits.

Half the age of their clients, the staff are spirited. One holds out a toy for the household cat, “Crunchwrap Supreme,” a stray found at Taco Bell. Keyt finally gets up to set the table for dinner and taps the right shoulder of each caregiver as he passes by to their left.

Keyt and Adam Nardi, a direct support professional, flatten mounds of ground beef with their hands. “I’m getting paid to barbecue,” says Nardi, who has worked with the agency five years.

This is the ideal, Bonnie Smith says, “A-plus.” She’s assigned much worse grades to her son’s caregivers in the past.

More than 400 state regulations govern how to run a group home. How to cook, how to clean, how to fill out paperwork - it’s a narrow path built with the hope it would lead away from the history of abuse that remains a legacy of the state hospital system.

Parents such as Bonnie Smith have spent the better part of their lives warding off harm to their children. When her son was 5, a pediatrician in New Orleans told her, “You have two lovely daughters. Put Brooks in a mental institution and forget about him.”

His treatment eventually led to Muscatatuck and Madison state hospitals, but Bonnie Smith kept watch. Once, a doctor increased Brooks’ dose of the powerful tranquilizer Thorazine to 600 grams, infuriating Bonnie. “That doesn’t put you to bed. That puts you under the bed.”

LifeDesigns CEO Susan Rinne understands why Brooks Smith is a “VIP.” His mother fought her way up to the U.S. Supreme Court and testified before Congress to move people out of state hospitals and into group homes. There is no going back, and an “A-plus” is not an easy grade to earn from someone like Bonnie Smith.

“When we see things out of order,” Smith said, “we complain.”

The hands caring for Brooks Smith at LifeDesigns are young but experienced, with years, not months, of time in the industry. But Bonnie Smith rolls her eyes when she hears the word “turnover.”

This group of staff she likes. The group before them, not so much.

Staff changes can be for better or worse. The year following the Options and Christole merger and the turnover spike, LifeDesigns’ nine group homes averaged more than twice the state average for deficiencies in Indiana Department of Health survey reports. A box spring at one home was rusted over where metal met a urine-soaked mattress. There was the time an overnight staff member was asleep on a couch, waking only to yell down the hall at a client who was throwing up in the kitchen.

Five of seven clients at one group home in Ellettsville lost their Medicaid coverage, which funds most group home care, either because the nonprofit’s staff allowed clients’ bank accounts to exceed Medicaid’s $1,500 maximum for eligibility or they failed to fill out paperwork to help clients renew the insurance. Two residents at another group home were also affected.

One resident who lost coverage was charged $260 for “foot and ankle” out of his personal bank account, even though LifeDesigns is required to pay for uncovered medical expenses. LifeDesigns eventually reimbursed everyone affected by the lapse.

The agency reduced its rate of turnover to 36 percent in 2013, but a bad year with violations of state rules was a reminder of what turnover can bring. Work isn’t always documented, support plans aren’t always followed, because somebody doesn’t always know what to do.

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