DD Ombuds SFY2024-2025 Annual Reports — END HARM abuse line non-functional; 75 people stuck in hospitals 60+ days; $9M residential abuse settlement
Two consecutive DD Ombuds annual reports document structural failures in DSHS Developmental Disabilities Administration oversight: the END HARM abuse-reporting line non-functional as a 24/7 resource, at least 75 developmentally disabled adults stuck in community hospitals for more than 60 days without medical need, and a $9M residential abuse settlement where Residential Care Services issued only one citation despite numerous complaints during the abuse period.
What happened
The Office of Developmental Disabilities Ombuds (DD Ombuds) publishes annual reports to the Legislature documenting systemic findings and complaint patterns across DSHS Developmental Disabilities Administration (DDA) programs. The SFY2024 and SFY2025 reports together document three overlapping structural failures:
END HARM abuse-reporting line
DSHS established the END HARM line as a 24/7 toll-free resource for reporting abuse of children or vulnerable adults. The DD Ombuds SFY2025 annual report (published October 31, 2025) documented a major problem: the line was routing callers to a phone that was not answered by a live person, and instructions referred callers to a website URL that was outdated. The Ombuds was meeting with DSHS to resolve the issues as of the report date. The Ombuds stated explicitly: “The END HARM line is still not a good resource for reporting vulnerable adult abuse 24/7.” This finding spans the SFY2025 reporting period (July 2024–June 2025) and may have preceded it.
75 individuals stuck in hospitals without medical need
The SFY2024 annual report (published October 31, 2024) documented that DDA reported at least 75 developmentally disabled adults stuck in community hospitals for more than 60 days in SFY2024 — not for medical treatment, but because DDCS had not arranged appropriate community residential services. The DD Ombuds stated that some individuals had been waiting in hospitals for more than a year. The SFY2025 report confirmed the problem remains prevalent in 2025: “Children and adults continue to be boarded in community hospitals without a medical need; they are not receiving the habilitative services they need, sometimes they are restrained and cannot go outside for the duration of their stay.”
Hospitals lack the capacity and clinical design to provide habilitative services for people with developmental disabilities. Hospital boarding of individuals without a medical need is both a service failure and a rights deprivation — individuals in this situation may be physically restrained and are denied access to outdoor space and the community-based services they are entitled to under Medicaid HCBS rules.
$9M residential abuse settlement and RCS enforcement failure
The SFY2025 report documented a $9M settlement paid by a DDCS-certified residential provider following a lawsuit alleging abuse and neglect of a person in its care. During the period in which the abuse occurred, the DD Ombuds reports that Residential Care Services (RCS) received and investigated numerous complaints about the provider — but issued only one citation, unrelated to the issues raised in the lawsuit. The settlement amount reflects the severity of the abuse; the RCS enforcement record reflects the gap between complaint volume and enforcement action.
Community Protection Program and HCBS compliance (SFY2024)
The SFY2024 report also raised concerns about the Community Protection Program (CPP), which the Ombuds described as the most restrictive community program administered by DDA. The Ombuds documented that CPP restrictions on residents’ rights were not consistently compliant with federal HCBS rules, and called for elimination of the program in its current form. This finding is not the primary focus of this case file but reinforces the structural picture: DDA’s most restrictive program was out of federal compliance during the same period individuals were being hospitalized for lack of community placements.
What the primary sources say
The SFY2024 Annual Report (DD Ombuds, October 31, 2024): “DDA reported that at least 75 people were stuck in the hospital in SFY 2024 for more than 60 days.”
The SFY2025 Annual Report (DD Ombuds, October 31, 2025): “The DD Ombuds uncovered a major problem with the END HARM abuse reporting line and is meeting with DSHS to resolve the issues.” And: “The END HARM line is still not a good resource for reporting vulnerable adult abuse 24/7.” On the $9M settlement: “During the period the person was receiving residential care, there were numerous complaints and resulting investigations, but only one citation was issued by RCS, and it was unrelated to the issues raised in the lawsuit.”
Status
Both reports are public legislative reports. No criminal investigation or formal legislative action has been documented as of this record’s last update. DSHS and the DD Ombuds were in active discussion about the END HARM line as of the SFY2025 report date. The hospital boarding problem remains open with no confirmed resolution documented.
Why it’s in the registry
Three documented failures across two consecutive annual oversight reports, each independently sufficient for registry inclusion: (1) a structural breakdown in the state’s primary abuse-reporting infrastructure for vulnerable adults; (2) a documented pattern of hospitalization without medical need affecting at least 75 people; and (3) a $9M settlement for residential abuse paired with an RCS enforcement record that shows a single citation during a multi-complaint investigation period. The pattern is consistent with the broader failure documented at the federal level in the HHS OIG adult family home audit (WA-2025-DSHS-HHA-OIG) — when state regulatory enforcement is inadequate, harm accumulates.
Reform implication
The END HARM line being non-functional is itself a reportable structural failure. When the agency’s own abuse-reporting infrastructure cannot accept reports — routing callers to unanswered phones or dead website links — the oversight chain is broken at its first step. The person trying to report abuse of a vulnerable adult has no pathway to reach an accountable human being. This is not a resource gap; it is an accountability gap. It should be remedied immediately as a matter of law, with independent verification of the fix rather than self-certification by DSHS. See [reform: dda_oversight], [reform: behavioral_health_capacity], and [reform: independent_inspector_general].
Reform implication
The two consecutive DD Ombuds annual reports document a system in which the first contact point for abuse — the END HARM line — is structurally broken, community hospitals are being used as de facto residential placements for people with developmental disabilities who have no medical need to be hospitalized, and a certified residential provider can generate numerous complaints and investigations and receive only one unrelated citation before a $9M settlement is reached for abuse and neglect. The END HARM line failure is not a funding gap or a capacity shortage — it is a design and accountability failure. The line was established to give developmentally disabled adults and their families a guaranteed 24/7 point of contact for reporting abuse. When that line routes callers to an unanswered phone or an outdated website, the oversight chain is broken at its first step. The person trying to report abuse has nowhere to go. The 75-person hospital backlog documents the downstream consequence of inadequate residential placement infrastructure: when DDA cannot arrange community residential services, individuals end up in hospitals that are not equipped to provide habilitative services and that may resort to physical restraints to manage individuals who are there without a medical need. This is a rights violation by any clinical or legal standard. The $9M settlement and the RCS enforcement record — one citation during a period of numerous complaints — is the enforcement failure pattern that recurs across Washington's oversight of congregate care settings. The same federal-escalation dynamic that produced the HHS OIG adult family home finding (WA-2025-DSHS-HHA-OIG) applies here: when state oversight fails to enforce its own rules, the harm accumulates until external review exposes it. Couple thematically with the Trueblood DSHS case (WA-2024-DSHS-TRUEBLOOD), which documents similar behavioral-health-capacity failures for a different population — civilly committed individuals — resulting in federal contempt. The structural argument is the same: Washington cannot place people with high-needs behavioral and developmental profiles in appropriate community settings, and the accountability mechanisms (abuse lines, RCS inspections, hospital boarding limits) are not enforced. See [reform: behavioral_health_capacity], [reform: dda_oversight], and [reform: independent_inspector_general].
Sources
- Annual Report on Activities SFY 2024 — Office of Developmental Disabilities Ombuds“DDA reported that at least 75 people were stuck in the hospital in SFY 2024 for more than 60 days. The DD Ombuds also stated they worked with several people this year who had been stuck in the hospital for more than a year.”
- Annual Report on Activities SFY 2025 — Office of Developmental Disabilities Ombuds“The DD Ombuds uncovered a major problem with the END HARM abuse reporting line and is meeting with DSHS to resolve the issues. The END HARM line is still not a good resource for reporting vulnerable adult abuse 24/7.”