A Hamilton County grand jury empaneled within days of the March 21 fire that killed four group home residents has issued a report that criticizes fire-drill practices and reveals the fire started in a waste receptacle on the home’s back porch, where employees sometimes smoked in violation of facility rules.
A 22-page report on the fire at the one-year-old, state-run Riverview Group Home for developmentally disabled adults in Wells was issued Tuesday by Hamilton County District Attorney James Curry.
The report, citing employee interviews, establishes that staffers often violated rules by smoking on the back porch, but it does not directly attribute the fire’s origin to smoking. However, the grand jury noted, investigators traced the fire to a green trash receptacle on the porch.
“In essence,” the report said of the investigation, “someone did something that introduced the source of ignition in the trash receptacle.” Because all evidence was destroyed in the fire, the report said, how the fire started and who started it cannot be determined. The grand jury made no finding on whether the fire was “intentional, reckless, criminally negligent, voluntary or involuntary.”
But it was clear the fire smoldered in the trash receptacle “for several minutes before there was any visible smoke or flames.” The fire then “spread rapidly and dramatically,” igniting the vinyl siding and spreading into the eaves and soffit before racing through an unpartitioned attic unprotected by the sprinkler system, the report said.
The state Office of Fire Prevention and Control issued its own report June 10, attributing the fire to “human action” but offering no explanation. A spokesman for that agency said in June that there would be no additional information about the fire’s cause until the grand jury reported.
The home was operated by the state Office of Mental Retardation and Developmental Disabilities through its subsidiary, Sunmount.
Corroborating OMRDD’s own finding that fire drill records at the home may not have been accurate, the grand jury concluded that records from Riverview did not provide “a realistic reflection of the actual time” it would take to evacuate the nine disabled residents.
Though some drills were unannounced, staff was usually alerted to a drill and thus able to prepare residents to be moved, “creating circumstances which would not accurately reflect the actual difficulties which would occur in a real fire,” the grand jury found.
The report said the staff had little training in fire safety and was generally unprepared for such a calamity. Experts and the grand jury identified a number of deficiencies, the report said.
A sensor, presumably in the attic, transmitted the alarm to an OMRDD subcontractor in Albany at 5:25 a.m. After a second alarm, an operator called the facility before contacting the Wells Fire Department. The procedure, the grand jury found, delayed the fire response and the evacuation as staffers interrupted their efforts to take the call.
The New York Civil Liberties Union, which represented five of the nine residents in the landmark 1972 class action suit that closed the Willowbrook State School and created the state’s group home system, said Tuesday the grand jury report “provides a tragic glimpse into the horrors that these people experienced in their final moments” in the Wells fire.
NYCLU Executive Director Donna Lieberman, commenting in a prepared statement, said the report emphasizes the need to ensure “design and construction of group homes is adequate to protect the highly vulnerable populations that live in them, and it must assign fire safety code enforcement to fire safety professionals, as opposed to employees in the state’s OMRDD who do not have the training and expertise necessary to fill such an important role.”
The grand jury’s report calls for group homes to adopt building code and fire safety standards appropriate to congregate care setting rather than standards that pertain to private residences, Lieberman said, noting that the stricter code standards would have ensured the attic was equipped with sprinklers and the roof structure built with fire retardant materials. The code for institutional, rather than residential housing, she said, would have provided time for the evacuation.
The stricter building codes for institutions “were circumvented by determining the homes were residential,” the grand jury said.
The grand jury speculated that these group home problems exist statewide. And it found “troubling” the fact that staffers on duty during the fire were never tested for possible alcohol or drug impairment.
Acknowledging the limitations and unanswered questions presented in its report, the grand jury called the work to improve group home operations unfinished and issued six recommendations:
* Create new state requirements for institutional building code standards for group homes.
* Assign fire safety code enforcement to the Office of Fire Prevention and Control.
* Require mandatory drug and alcohol testing of all group home employees.
* Give Fire Prevention and Control new authority to investigate any fire in the state. Currently, the agency must be invited to investigate by the state agency in charge of a facility.
* Establish minimal qualifications for all employees caring for developmentally disabled individuals.
* Outside police agencies should investigate allegations that fire drill and related records may have been falsified at the Wells home.
OMRDD officials did not return calls for comment Tuesday.