Months after three Utahns with disabilities died in the care of a Utah company, its license has been revoked and a caretaker charged with murder. 

And now a watchdog organization is calling attention to its view of the state’s role in what happened that day in February, when authorities say the group was left alone in a vehicle for hours.

“This tragedy occurred because DHHS (the Utah Department of Health and Human Services) allows high risk providers to serve individuals with complex support needs and large budgets to support those needs without appropriate oversight and accountability,” the Disability Law Center said in a report released Monday.

Program for Utahns with disabilities loses its license following deaths of 3 clients left in van

The report reiterates criticisms the agency has been raising for more than a decade, said Nate Crippes, the center’s public affairs supervising attorney, in a prepared statement.

“Too often, Utah has prioritized facilities and profits over the wellbeing of Utahns with disabilities, and we, once again, urge State Officials to review our recommendations and make the necessary reforms to protect those in long-term care settings,” Crippes said. 

In its report, titled “Profits Over People,” the center says the department should have known that Safe and Sound Services was a “dangerous provider.” The state agency had been told of problems like physical assaults and failure to provide medical care for injuries prior to the deaths of the three men last winter, the center said. 

The Department of Health and Human Services conducted inspections of the company in the years leading up to the tragedy and found employees worked with clients unsupervised even though they hadn’t done required background checks, among other issues, the report notes. 

But it says those evaluations were either conducted remotely or when no clients were present — giving inspectors little opportunity to talk with clients and see for themselves how the company administered services. Safe and Sound could not be reached at a publicly listed number Monday.

After the men’s deaths, the department checked on the company’s residential sites and noted a variety of issues, including a foul smell and no heat or running water in one location, staff admitting to locking residents in a basement at night in another, and employees reporting a resident returned from a day program with a broken tooth, black eyes and scratches on his neck, the report states. 

“These complaints all demonstrate the provider was not using the money appropriated by DHHS to provide even basic utilities or a clean environment,” the report states. “Staffing ratios were dangerously low and insufficient to provide the care the state had contracted for.”

The Department of Health and Human Services did not make its executive director, Tracy Gruber, or any other administrator available for an interview Monday. 

In a prepared, unsigned statement, the department said “the stories outlined in the Disability Law Center’s report weigh heavily on us. When safety is compromised and lives are lost, we feel it deeply. We absolutely agree that taxpayer dollars should be used as intended.”

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The department said it identified many of the same concerns through an internal review process and in response, it has hired a contractor “to assess and mitigate the risk of abuse, neglect, and exploitation for people with disabilities.” The statement did not identify the contractor. 

Among the other changes the department has made: hiring a new quality assurance administrator, along with four new employees working in oversight and technical assistance. 

Looking forward, it said it’s also exploring ways to keep problematic providers from getting contracts in the first place and to raise the qualifications needed for agencies to serve those with disabilities. 

In Utah’s 3rd District Court, transport driver Isaiah Vaughn Pulu, 26, has not yet entered pleas to three counts of murder in the February deaths of Colton Warren Moser, 25; Mosa’ati Moa, 22; and Tim Jones, 39. An attorney for Pulu has previously said the deaths were a “tragic accident.”

Transport driver charged with murder after 3 Utahns with disabilities died in state custody

Prosecutors allege he drove the men who required round-the-clock supervision — two of them nonverbal — to his home in West Valley City. The men remained in the vehicle while investigators say Pulu went inside to eat and watch television, reporting he left the garage door open, but when he returned about four hours later the door was closed and the men were unconscious. 

He had been reprimanded a month earlier for “client abandonment” after leaving three people unsupervised for a half-hour, prosecutors alleged, without identifying those clients. 

The Disability Law Center report also identified issues in facilities serving other populations, including the Provo Canyon School, a youth residential treatment center that was shut down by the state earlier this year. It laid out a host of recommendations for the state, including requiring service providers to show they can safely care for clients before receiving a license. It also urged the state to bring on more employees helping to oversee such companies and raise their pay. 

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