LITTLE ROCK — Editor's note: Information in this story is sexually graphic and may offend some readers. For years, Anthony has sexually preyed on fellow residents at the Conway Human Development Center.
Anthony's aggression, generally against other men, has been relentless and barely contained.
He has sexually attacked others as they used the bathroom or watched TV. He has climbed into their beds as they slept. He has followed them outside to the patio after meals and rubbed his sexual organ on their faces and heads.
The 576 residents at the Conway center are extremely vulnerable. They range in ages from 10 to 64. They are mentally retarded. Most were born with other conditions such as epilepsy, autism, cerebral palsy, spina bifida or Down's syndrome.
Anthony's actions were not reported to regulators or to the families of some of the residents he victimized, which is required by federal law. In February 2001, the state Office of Long Term Care cited the center with one of its most serious deficiency ratings after receiving a tip from a Conway employee.
"The facility failed to intervene timely and failed to intervene in a manner to protect 10 clients from repeated acts of sexual aggression by [Anthony] who lived in the same unit as nine of the 10 clients," the report stated.
Investigators reviewed records for a six-month period.
Bob Clark, the center's superintendent for 21 years, assured his bosses at the state Department of Human Services that the problem was under control.
"While it may be a very serious citing, it will be easy to fix as the staff were not documenting that they were following the plan that they devised," Clark wrote in a March 1, 2001, e-mail.
"P.S. There is no systemic problem that has displayed itself."
No one at the Conway center told investigators that Anthony (not his real name) had been sexually assaulting others for at least 10 years.
Nor, at that time, did anyone reveal that seven more residents continued to be sexually aggressive against other residents.
Since February 2001, the Conway center has been cited six times by state or federal regulators for failure to protect the center's residents. An investigation by the Arkansas Democrat-Gazette has gone beyond the regulators to document long-term patterns of unreported abuse, medical practices now being questioned, and a superintendent intent on protecting the status quo.
The newspaper has found that the Conway Human Development Center : Failed to report physical and sexual abuse of residents against other residents.
Failed to accurately describe abuse by staff against residents, downplaying abuse as "discourteous treatment."
Failed to restrain residents properly.
Failed to check medical credentials of doctors.
Failed to alert some families that their relatives have been victims of sexual assaults.
These issues will be detailed in subsequent articles in this series.
Marsha Smith, a client advocate, reviews incidents of abuse or neglect reported to the state Department of Human Services.
"I sense that some salient principles of client protection are not grasped by Conway Human Development Center," she wrote department Director Kurt Knickrehm in a March 25, 2002, memo.
"I do not regularly see such blatant problems and cavalier disregard for expectation from other facilities."
Clark has since resigned under pressure, effective June 30. What the Conway center did - and didn't do - with Anthony reflects problems that still exist at the facility where some residents depend on caretakers for their every breath.
This is a story about politics, personal power and trust betrayed.
For families unable to care for or control mentally retarded sons, daughters, brothers and sisters, Conway's cottage-style campus has seemed like a haven since it opened in September 1959 as the Arkansas Children's Colony.
It is the oldest and largest of six human development centers. Others are at Alexander, Arkadelphia, Booneville, Jonesboro and Warren.
With only a little help, some of the men, women and children at the Conway center dress, eat, bathe and take medicine. A few function well enough to hold jobs such as shredding paper or emptying garbage containers for local restaurants.
For others with severe brain damage, the soft touch of a hand on their cheeks, the sound of a special song, or a taste of their favorite ice cream elicits a childish gurgle or a highpitched scream of delight.
After months or years of practicing to do what others take for granted, they may hold a spoon, shake their heads "yes" or "no," or communicate by blinking.
Nearly 200 of the residents are both mentally retarded and mentally ill. They gouge their own eyes and bite deep gashes into themselves, other residents or staff. Some have been known to swallow an entire bag of plastic gloves or eat garbage.
About 1,200 employees at the Conway center labor with these members of the family of man.
Thousands of grateful relatives have seen their sons and daughters progress from cradle to grave at the Conway center. They praise its staff and Clark for their dedication.
John Francis, for example, moved his son and a daughter into the Conway center in 1968. "It's been a God blessing for us and others," he said. "We knew our kids were capable of much more if they had people with a knowledge of how to train them in such things as tying their shoes. They do a fantastic job. If we had a problem or question we would get it worked out.
"I've never regretted a moment of putting them where they are."
But that was not the case for everyone.
On Feb. 23, 2001, a seemingly reassuring memo landed on Superintendent Bob Clark's desk.
It was written the day after state investigators cited the center for failure to protect its clients against Anthony's sexual aggression.
"Although there is no documentation showing who is responsible for [Anthony] at times... there is ample staff to provide this supervision and it's effective," wrote Mark Stitch, a team leader since 1994 over the cottage where Anthony lives.
Stitch additionally reported to Clark that "The staff... are very aware of Anthony and his tendencies. They are very experienced and typically do a good job."
Yet, three days earlier, Anthony had sexually attacked two other residents.
According to a Feb. 20, 2001, behavior incident report: "Anthony was over Resident A in the bedroom trying to get him to touch his penis." The other resident resisted.
Later that day, "Anthony was trying to force Resident B's head down in his lap, but that resident yelled and resisted."
After the second incident, Anthony was put in a jumpsuit that hindered his movements. And earlier that month on Feb. 7, 2001, "Anthony climbed on top of Resident C who was lying on the couch. Resident C started yelling."
Stitch defended his memo during an interview.
"Well, effective and perfect are two different things," he said. "We cannot ever know everything that's going to go wrong. But I can tell you what we have is, for the most part, effective."
However, the Conway center's internal records show that its staff had been concerned for years about the facility's failure to protect other residents from Anthony.
Clark said he was not aware of the severity of Anthony's problems even after the state investigation in February 2001. In October, he gave the Democrat-Gazette three reports from 1998 and one from 1999 in which Anthony was attempting to obtain oral sex from other residents.
Clark said Stitch had discovered the reports while researching a state Freedom of Information Act request for the newspaper.
"I believe that if this team leader had known it, he would have brought it to my attention. I would have immediately addressed it in 1998," Clark said.
But documents show that Clark was told in 1998 that Anthony was violating the rights of other residents with his sexual actions. When Anthony's parents offered to pay for a staff member to watch their son, Clark was asked to be involved.
"I tried to work that through the state system. It was just unworkable," Clark said.
Those four incidents were not the only records of Anthony's aggression against others at the Conway center.
Anthony forced himself sexually on others approximately 25 times and rubbed his penis on other residents or exposed himself 41 times in a threeyear period, according to records analyzed by the Democrat-Gazette.
For example, on July 9, 1998: "Anthony was found with his shorts down. ... He had his knees on Resident D's head of his bed and was trying to put his penis in Resident D's mouth. That resident was sound asleep until he was rudely awakened. Resident D began to cry," the report stated.
Clark subsequently labeled Anthony's actions "very inappropriate" and disputed findings that those actions were sexual abuse, saying Anthony did not know what he was doing.
The reports about Anthony were never upgraded to incidents of abuse or neglect and sent to the state Department of Human Services as required by department policy and state and federal laws.
"They didn't react appropriately or timely with Anthony," said David Fray, director of Developmental Disabilities Services. That division of DHS oversees the $43 million in state and federal funds that keep the Conway center running.
"If Bob had reported it to us and requested additional help, we would have given him emergency resources," Fray said. "You don't take a molester and place him in the middle of a group of people."
It was 1975 when Anthony first arrived at Conway Human Development Center. He was 15 years old but functioned at the level of a 16-monthold.
He eventually was placed with the Sheltered Living Team, which oversees the mentally retarded who are more independent and mobile.
In 1994, a psychiatrist diagnosed Anthony with a sexual disorder and recommended a drug to decrease his sexual activity. But Anthony's family refused. Under federal law, the center needs the family's permission to administer drugs.
Two years later, a psychiatrist again suggested that Anthony be put on drugs. His family refused. His family has declined to be interviewed for this story.
By 1997, Anthony's behavior had worsened, particularly at night.
"Staff should always know where he is and what he's doing - monitoring critical after bedtime," a June 1997 note reads.
The center, with the approval of Anthony's parents, installed an electronic monitor that beeped when Anthony got out of bed, warning the staff that he was on the prowl.
That did not deter Anthony. He began to track down residents in the bathroom and on the patio during the day.
Anthony was supposed to have a special staff person assigned to him during the 4 p.m. to midnight shift.
Despite his increased aggression, the Conway center's supervision of Anthony was haphazard. Plans to control his behavior were written but not always followed.
On Jan. 1, 1998: "Anthony left the bathroom by a different door and staff did not notice. He was found in the dayroom standing in front of Resident E who was sitting on the couch," a report stated. He tried to force the other man to perform oral sex.
"Resident E did not like what Anthony had done to him. He looked as though he could cry," the staff member wrote. "Anthony was verbally told to stop."
For years, staff simply gave him a "verbal reprimand" no matter how forceful he was with others.
"There are no consequences to Anthony for this behavior. He is only removed from the situation," a Feb. 9, 1998, memo stated.
Stitch explained, "Once you stop whatever was happening from happening, we usually don't do any type of punishment."
The center had limited expectations for Anthony.
Anthony should "exhibit no more than one incident of sexual misconduct per month for 10 out of 12 months," according to a 1998 report. That same limit was set each year, although he always exceeded it.
"That astounds me. It should be a zero goal," said David Hingsburger, a behavior therapist from Canada who has worked for 20 years with the mentally retarded who have sexual disorders. He recently lectured in Little Rock to personnel from the human development centers.
"How is the staff supposed to take it seriously with a goal like that? You assign people to him at all times. And he is never with other residents. He sits at another table by himself at lunch. He is in the bathroom by himself. You don't have this guy sleeping in a room with anybody else.
"It's a parallel life and that's OK as long as he's getting treatment. You have to take every step possible to be sure that residents are safe because we have the absolute responsibility to those who are in our care."
There were occasional references in the records to residents who were forced to fight Anthony off in the bathroom or the patio or in their own beds.
"There were eight residents targeted by Anthony in the last year. Four of them appeared to be upset and actively resisted. ... New staff in the residence were unaware of the amount of supervision Anthony requires," a May 1998 memo stated.
"Something must be done as soon as possible for protection and rights of individuals that he is sexually aggressive toward," a Human Rights Committee memo of Oct. 28, 1998, stated.
That Conway center committee reviews the records of residents who may need behavior-altering drugs, restraints or more supervision.
On that same day, after the committee met, Anthony was written up for incidents with four other residents; three involved attempts to force oral sex.
A month later the center designated a staff person to watch Anthony from 3 to 11 p.m.
The Human Rights Committee in November 1998 again stressed the need to protect other residents.
"Members expressed their strong feelings that Anthony's behavior interferes with the safety and rights of other individuals who live with him."
A year later, that plan to watch Anthony had not been followed. There had been at least 11 assaults in the intervening months.
"Anthony's one-on-one [staff member ] was gone for a while, then returned in September. ... It is unknown if this [staff member] is back on a permanent basis," a Nov. 8, 1999, memo stated.
The aggression continued in 2000. Among the 18 incidents were: On Aug. 22, 2000: Anthony was naked in the toilet stall. Staff noticed movement in bathroom after five minutes and found Anthony trying to put his erect penis against Resident D who was crying and did not like Anthony "messing with him."
A restraint jacket was used as an emergency restraint for sexual misconduct in August 2000. On Oct. 9, 2000, for the third time, the Human Rights Committee stated, "something must be done regarding the rights of others that live in Anthony's home."
The committee suggested that a special meeting be held by the interdisciplinary team of professionals to discuss how to protect other residents from Anthony. Four months later, that meeting had still not been held.
"I think possibly it fell through the cracks," said Diane Lucas, a 26-year Conway center employee and head of the committee at that time.
"I think everybody just felt like we should try our best for him and others.
Sometimes human error plays a part."
Marsha Smith was puzzled by the state's investigative findings on Anthony.
As client advocate, she reviews and assesses all incident reports. A sexual perpetrator did not sound familiar. She checked her files.
A 1999 DHS policy requires abuse to be reported as well as "any other patients' rights violations which jeopardize the health or quality of life of any person in DHS custody." Previous policies also addressed this issue.
"Despite this requirement, I find no incident reports pertaining to any of the sexual incidents noted in the OLTC survey," Smith wrote in March 2, 2001, e-mail to DDS director Fray.
"Meetings of Treatment Teams reflect significant violations were occurring," she added. "Clients crying over the unwelcome advances of another from whom they are not being protected would certainly qualify as a quality of life issue."
Protection from abuse falls under at least two DHS policies as well as state and federal laws.
The most recent state incident reporting policy was sent to the Conway center in May 2000 by Carol Shockley, director of the Office of Long Term Care.
"Residents must not be subjected to abuse by anyone, including, but not limited to facility staff, other residents. ... Sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault," the memo stated.
And in July 2000, the human development centers were sent: "
Clarification on citing deficiencies for situations involving abusive behaviors by demented residents."
"When actions by a demented resident constitute inappropriate behavior and/or may be a threat to other residents or himself, the facility is accountable," according to a memo from the U.S. Department of Health and Human Services.
Two weeks after the state deficiency citation, Clark notified his team leaders on March 6, 2001, "We have generally viewed the Incident Reporting policy... as relating to staffto-client interactions. Due to the recent events, we are going to take a much broader view of this area.
"Effective immediately, we will report instances of assault that results in any injury or sexual misconduct on a 'client-to-client' basis."
On April 13, 2001, the federal Centers for Medicare and Medicaid Services also cited the Conway facility for not protecting residents from Anthony. Some of those residents were violent.
The Conway center had insisted that Anthony had extra supervision only at nights because that is when he was most active. Investigators found numerous instances of attacks during the day.
But Anthony was not the only sexual aggressor. The federal investigators discovered that "the facility has failed to take preventative or protective actions following such attacks for 11 of 11 persons exhibiting such behavior in the past six months."
The Conway center was also cited for not having any plans to prevent unwanted sexual advances by one resident against another.
The federal plan required enhanced supervision for several of those residents.
In two cases, the supervision was discontinued in September. It had to be restarted because sexual incidents increased, according to records obtained under the state Freedom of Information Act.
Before the Conway center submitted its plan of correction to the state, Fray wanted to review it. He asked for specific items addressing Anthony's problem to be included.
They were not.
"At no time did I give permission for the plan to be submitted," Fray complained to his boss, DHS Deputy Director John Selig in a March 13, 2001, memo.
"I am concerned that my directives are not being taken seriously and were not followed by Bob Clark."
Fray was worried about the residents who lived with Anthony.
He suggested that Anthony be moved to the Booneville Human Development Center. Its 8,500-acre campus had separate rooms and cottages, which Conway did not have.
Fray made some suggestions for the federal plan of correction, specifically about Anthony, and asked Clark to provide him with the final report before returning it to federal investigators.
Clark sent an e-mail to the center's quality assurance coordinator on Tuesday, June 5, 2001: "Send whatever you have on the plan of correction to David and anyone else he desires, but do not rush through this just to get something out so everyone can see it. I have submitted over 40 plans of correction in my tenure and they have all been accepted."
Fray expected a response from Clark.
"Has it been submitted? Have you taken any action or incorporated into your plan of correction my concern regarding removing the sexual perpetrator (even to Booneville HDS or off campus) from the living quarters where others have been attacked," he e-mailed Clark late Friday afternoon, June 8, 2001. "I want to know what is said and how the issue of safety was addressed."
Clark replied the next Monday morning. "David, the federal plan was submitted Friday at 3 p.m. and you are copied, however I will fax you a copy when everyone gets here. But I did not say that we would transfer anyone to Booneville or elsewhere, rather identified the 'enhanced' supervision aspect.
"I am not opposed to a recommendation of such, but I feel like it would be 'dumping' on Booneville. This man will have the same problem wherever he is. ... The parents of the man live in [deleted]. I think the team believes [moving Anthony ] will be a real hardship on them."
On June 28, 2001, a Conway center team met to review Fray's proposal that Anthony be separated or sent to another facility with individual rooms. They decided to leave him at Conway.
"Current behavior interventions seem to be effective," the team concluded.
It added "the parents /guardians are adamantly opposed to moving Anthony... the Conway Human Development Center has been his home for 27 years. They feel a move would be detrimental to Anthony."
"Anthony's functioning level is lower than most residents at the Booneville Center, which could make him vulnerable to others."
Clark replied to the team, "I am in total agreement at this time..."
Fray was frustrated. "This seems to me to lack common sense sensitivity to victims and their need not to be around him," he wrote Selig.
In an interview, he added, "No matter what their disabilities, surely on some level, they look at him and fear him."
Other resident protection issues surfaced. The federal investigators had cited the Conway facility for: Failing to report allegations that staff had pushed down, head butted or choked residents to the state and the Attorney General's Office.
Failing to adequately investigate injuries of unknown origin for 18 of 19 people to determine if accidents were the results of abuse or neglect by staff or if they could have been prevented.
Clark had approved closing those investigations without further scrutiny, saying his staff's examination had been thorough.
In May 2001, another state investigation cited the Conway facility for failure to protect its residents. Two of the incidents involved residents walking off the grounds, unnoticed.
After returning from an outing, a male resident wandered away from the facility in November 2000 and was hit by a car. He suffered compound fractures in both legs and a fractured arm. The facility did not know he was missing until the police called an hour later.
Another resident, in May 2001, walked away while residents were preparing for a recreational tractor and trailer ride. He was missing for 19 hours.
In June 2001, two injuries of unknown origin surfaced when investigators returned to review files. The injuries had not been reported to the state. The Conway center was not following its own plan of correction. In August 2001, a state investigator witnessed one client pull another client's pants down and attempt to lay on top of him. No staff members were in sight.
It was not as if the staff members were all busy elsewhere. The state investigator found three staff members in the kitchen and a fourth standing in the dayroom by the kitchen entrance. No residents were in the kitchen.
The Conway center was again cited for failure to provide supervision to prevent sexual abuse.
On the basis of the center's continued failure to report abuse and to protect residents, Fray recommended that Clark resign or be fired.
"The only thing I did at Conway was try to fix Bob's problems," Fray said. "I was not out to get him, but I was trying to clean up his mess. I wanted those people protected. He was fighting me every time I turned around."
Fray, director for nearly two years, was about to get a lesson in politics.
Clark recalls the first day he walked into the Conway Human Development Center. He was 18 years old.
"I got a job in the kitchen, and I was glad just to get on that pot sink and work," he said. "Then I was promoted to move over to the storeroom where I issued supplies to all of the units."
Born outside of Greenbrier, he was the second of three boys. His father worked at the shoe factory in Conway for 27 years. His mother, primarily a homemaker, sometimes worked at a local department store.
"We were poor folks. I mean it took everything Mama and Daddy could make just for us to get by," he said.
Clark held part-time jobs, including work at the Conway center, as he earned an associate of arts degree from Central Baptist College and a bachelor's degree in business administration from the University of Central Arkansas, both in Conway.
The Conway facility was something the town pointed to with pride. It had developed a national reputation as a model program for the developmentally disabled.
Clark worked in a variety of jobs before he was named superintendent in June 1980. He was then 31 years old.
"I've been here for 12 years, and most of the people who have known me will respect what I do," Clark said in an interview at the time of his appointment. "I don't play politics."
The facility name was changed from the Arkansas Children's Colony to the Conway Human Development Center in 1981. As new medicines were developed, the residents of the center began to live longer than generations before them. Today, there are fewer than 50 children among the nearly 600 residents.
The center, with nearly 1,200 workers, is the fourth-largest employer in Faulkner County.
Five other much smaller human development centers were eventually added to complete the Arkansas system. Superintendents came and went at the other development centers, but Clark remained at Conway.
He and his wife, Buneva, raised four daughters. As superintendent, he spent many of those years living in a modest house on the Conway center grounds.
He built a faithful following of families whose lives would be forever changed because the Conway facility took over the care of their sons and daughters.
One letter written in 1999 discusses a resident who had lived at the center since he was 8 years old. It was provided to the newspaper by Clark, along with a dozen other letters praising the center. The names of the families were blocked out.
"We can't find the proper words to express our deep appreciation for the 32 years you have cared for [name deleted]. We have never, in all these years, seen or heard anything that would be detrimental to his care.
"Without a doubt, he would not be alive today, nor our parents, if it were not for the center. We can never thank you enough."
But Clark's no-holds-barred style when confronted did generate fear and anger among other parents.
Cynthia Walker clashed with Clark after putting her 14-year-old daughter, Rachel, in the center in 1996. Walker fought over the personal education plan the center had written for Rachel.
"During that process, Bob Clark tried to make me and my husband look like two raving lunatics. It was ridiculous," said Walker, who now lives in Ohio. "You get branded as a troublemaker, and they try and kick you out. They were trying to put my daughter in a nursing home."
The state Department of Education upheld Walker's complaints in 1999 and cited the Conway center for deficiencies in several areas. The investigation concluded that the Conway center "had limited understanding of the rules and regulations governing procedural safeguards afforded students with disabilities."
Clark became a dominant presence at the quarterly meetings of the Developmental Disabilities Services Board.
That seven-member DDS Board consists of citizens appointed by the governor to oversee the human development centers.
"What little knowledge I may have gained, I try to share with anybody that really wants to know," Clark said. "I've worked in every aspect of a human development center, and I feel like I've got a pretty good handle on what works."
"I do know I carry a lot of informal authority, and I would be remiss to say not," he said. "Sometimes you have to be pretty autocratic and that don't win you a lot of friends, and I'm not hesitant to do that when I have to.
"People in the community, many of them I know resent me and hate me because they say, 'Bob Clark, institution.' "
"I've been offered lots of other jobs. I would have made a lot more than this with a lot less grief, but I love this job."
One of Clark's biggest fans has been Ron Carmack, chairman of the Developmental Disabilities Services Board. Carmack is retired as vice president for facilities of Arkansas State University.
Carmack has an 18-year-old grandson at the Conway center. The boy functions at a 1-year-old level. "We could live anywhere in this country, but we chose to have our boy at the Conway Human Development Center. That's saying something," he said.
And Clark's performance as superintendent ?
"I don't know any state employee or any person who had worked harder for people with developmental disabilities and who deserves more credit than Bob Clark," said Carmack. "A lot of retarded people owe him a lot. I don't know of any man I respect more."
Carmack was not disheartened by the critical findings in the state and federal investigations.
"We've never viewed any level of failure as acceptable," he said. "Every review is a chance to do better. We are taking it to heart, but one thing is clear: The job ain't easy."
During 2001, six state reviews, three federal investigations and a special report by the University of Arkansas for Medical Sciences criticized care at the Conway Center.
As the same issues surfaced - failure to protect residents and failure to report abuse - Carmack vigorously defended Clark.
Any institution of Conway's size would always have some deficiencies, Carmack said. To make things worse, the constant scrutiny had caused serious morale problems for the staff. It also frightened parents who feared that the center would be closed.
He pointed to high employee turnover and the inability to compete for more qualified staff when the center was paying minimum wage.
"I think if investigators leave with no more than what they left with, it's a glowing endorsement," he said.
Carmack did say that Anthony should have been handled better. He explained that he was not aware of the situation until the state uncovered it.
"He's had these tendencies the whole time he's been at Conway," Carmack said. "I think we screwed up this time. The fault lies in our team. It didn't kick into that level of concern and response that it should have. His actions were serious."
He added, "I don't hear a great outcry from the other parents who are in that cottage. They know that young man. They know his habits."
But were other parents aware of the scope of the problems, not only with Anthony but with other residents who were sexually abusive?
"It's possible they knew," said Clark. "But we did not point this out to them saying, 'This man has these types of behaviors and he rubbed his penis on Joe's leg yesterday or he walked by him and rubbed his penis on him.' "
Representatives of some of the parents associations and even some DDS Board members did not learn of the details of the investigations until late in the summer when Fray called them to his office to review the reports.
Newsletters to the Conway center parents did not mention the reports, according to Susan Fennell, former president of the parent association.
One DDS Board member refused to discuss the situation with a reporter saying, "I haven't read those reports. Ron [Carmack] keeps us abreast of what we need to know."
As investigators discovered problems in addition to the sexual abuse at the Conway center, superintendents at the other centers grew anxious. Fray made it clear that the lessons being learned at Conway were going to change procedures at all six facilities.
He wanted to create a special unit for residents who were both mentally ill and mentally retarded. That unit, to be located at the center in Warren for children and the center in Booneville for adults, would treat sexual offenders and the more violent residents.
In late July 2001, Fray returned early from vacation to attend a DDS Board subcommittee meeting on his proposals.
"I had a superintendent look me in the eye and say, 'You're not invited to this meeting,' " Fray said. "I laughed. I thought he was joking. I stayed. I found out later that they had asked my representative before I got there to leave the meeting. And she had. I was furious."
The ongoing fight over what to do with Anthony and other sexual predators had broken an uneasy truce between the board and DHS. For years, it had not been clear who legally governed the development centers: the DDS Board or DHS.
Laws passed between 1955 and 1985 creating both entities provided enough overlap in duties to cloud the issue of who had ultimate authority.
The law stated that the board is the administrator over the human development agencies.
But because the superintendents and their staffs are DHS employees and because the funding is funneled through DHS, Fray felt that Clark and others needed to answer to his division as well as to the board.
That made day-to-day operations and hiring and firing of superintendents unclear and at times contentious.
Fray continued to press for Clark to step down. But Clark's support base of families translated into political clout. That made his bosses, Selig and Knickrehm, uneasy.
Selig and Knickrehm were interviewed twice by the Democrat-Gazetteabout the sexual attacks. Clark had assured them no force had ever been used by Anthony against other residents.
And Carmack had told them he had reviewed the issue and there was no problem, Knickrehm said.
During the second interview, the newspaper told Selig and Knickrehm that residents had been forcefully sexually abused by Anthony and that others with sexual and violent behaviors were still not isolated at the center - other residents were still at risk.
Each time, Selig and Knickrehm quoted Clark and the DDS Board as saying all had been corrected. They asked the newspaper to hand over its documents and prove its point.
The newspaper had gathered 7,000 pages of reports, e-mails and memos from DHS by October 2001, using the state Freedom of Information Act. Copies were stored separately by topic at DHS headquarters. The newspaper offered to identify which files to read.
Concerned about the safety of residents, the newspaper called Gov. Mike Huckabee's office three times and left messages. He never returned the phone calls.
Selig and Knickrehm told Huckabee and a legislative subcommittee that Clark had reassured them that the problems were under control, although the newspaper was hinting that was not true.
Their assurances were about to backfire on them.
"We don't have a sexual perpetrator on this campus."
When Bob Clark was interviewed in late October, he wanted to make his view about Anthony very clear.
"He hasn't assaulted anyone. He has had his penis out. He's wiped it on someone's leg. He's wiped it on her face. He's wiped it here and there. But he hasn't assaulted anyone."
What would he call that?
"Very inappropriate," Clark responded.
He said Anthony's limited intelligence would not let him form "intent," and so his actions could not be considered predatory or an assault against anyone.
Anthony's parents, under pressure from the Conway center, had finally agreed to put their son on medication in August, Clark said. The center had also built a separate bedroom for Anthony by adding a wall.
For the first time in more than a decade, Anthony had strict supervision. Other than minor incidents of exposing himself, Anthony had not attacked any resident since February 2001, Clark said.
Why hadn't Clark or his staff reported Anthony's actions to DHS?
Clark said the reporting laws on abuse were vague and he did not consider the clause - "significantly jeopardizing the quality of life" - in the DHS policy to apply to situations like Anthony's.
He provided the newspaper with four incidents that he said team leader Stitch had just discovered. Three involved unwanted oral sex. He said these were the only incidents involving force.
Stitch had written Clark a memo saying he had interviewed staff members - one employee had been around Anthony for 10 years and another for six years - and no one recalled any force being used with his sexual advances.
Clark said he was appalled by the four instances.
"He was forcefully putting his penis into another client's mouth," the report from June 12, 1999, stated.
The parents of the victims in the four incidents in 1998 and 1999 were called recently, Clark said, but were not upset.
"We don't have a problem with that," he quoted the parents. "We understand who you're dealing with, and we all know that man."
Federal law requires that parents of the aggressor and his victim be notified of "any significant incidents." The guidelines for investigators define significant incidents as abuse "or any changes in the individual's condition... that is perceived to have some level of importance to the individual, family or guardian."
Clark said staff members were now "more sensitive" to the issue and were going to notify parents in the future if their children were victims of unwanted sexual aggression.
DDS Board chairman Carmack was informed about those four reports by a reporter. He said he would ask Clark about them.
"Bob's phone response was there were some observed consensual contact that was probably inappropriate," Carmack said, when contacted a week later.
After the interview with Clark, the Democrat-Gazette contacted state Sen. Percy Malone, chairman of the Senate subcommittee over human development centers.
Malone, whose district includes the Arkadelphia Human Development Center, was not aware of the long list of assaults by Anthony or how aggressive he had been. He set a subcommittee meeting to discuss the situation.
On Jan. 8, 2002, the subcommittee was assured by DHS officials and Carmack that mistakes had been made but were being corrected.
Malone called Selig and Knickrehm to the witness table and warned them he would continue to check "so we believe what we are being told today is true."
Clark was not asked to testify at the hearing. He sent DHS and Malone a response to questions raised about Anthony.
"His inappropriate sexual activity most often involved exposing himself or trying to rub against someone," Clark wrote. "He is not a sexual predator. His behaviors could be better described as annoying, bothersome, a nuisance and certainly inexcusable.
"However, this is NOT sexual abuse."
On March 6, the Democrat-Gazette met with DHS chief counsel Lee Thalheimer and outlined incidents the newspaper had uncovered of other sexually-active residents and the Conway center's failure to protect residents in an array of other areas.
Clark responded by reviewing all of the incidents involving Anthony from July 2000. He created a chart of incidents with three categories: Sexual, Non-Sexual Touching and Other.
Twelve incidents were labeled as "Sexual."
Under "Other" Clark included "trying to put other's mouth on his penis" and "erect penis sticking out, standing over another client."
Knickrehm formed several committees to look into the allegations by the newspaper.
The reports criticized the Conway center in several areas.
M. Catherine Lyon reviewed incident reporting. She had previously been director of DHS Adult Protective Services and now runs a private firm.
She stated that the Conway center was obligated to meet reporting requirements set up in DDS policies as well as state and federal laws.
"Whereas these resources are not necessarily consistent in their language," she wrote, "I have discovered no area wherein they contradict one another as they relate to the facility's responsibility to report."
The intent of the Adult Abuse Act is to protect endangered or impaired adults, she stated. "The statute's definition of sexual abuse does not include a measure of intent regardless of the IQ of the perpetrator.
"The first step in protection is reporting, not accessing for accountability or likelihood of prosecution."
While reviewing the files, Lyon uncovered six other incidents that she believed should have been reported to the state. Two of those, she said, needed further investigation.
"The clients aren't being considered," Fray said. "It's a turf war between Clark and the DDS Board against everyone else. They are forgetting that the system is here for these people, and we are failing them.
"At what point do we all know about the problems at Conway and say 'Enough is enough?' "
Knickrehm finally told Carmack that Clark must either retire or be fired.
On March 30, the 53-year-old Clark told his staff that he was resigning, effective June 30. "After much prayer and deliberation with family and friends, I would like to offer my resignation as superintendent of this wonderful facility," he wrote in his resignation letter, which he handed to the staff.
"Buneva [his wife] and I are ready to join the ranks of the retired and spend more time with each other and with our extended family."
He resigned to Carmack and the DDS Board. Knickrehm, Selig and Fray learned of the resignation from a reporter.
Carmack told the newspaper that Clark was not forced out.
However, a month later, the entire situation took another twist.
Knickrehm had asked Attorney General Mark Pryor to issue an opinion on whether the board or DHS had operating authority as well as hiring and firing control over superintendents.
On April 29, the opinion came out, shocking DHS.
The DDS Board, not DHS, has primary control, the opinion stated.
Although an attorney general's opinion does not carry the force of law, Pryor's opinion tilted the political playing field toward the DDS Board.
A short time later, Clark began contacting the governor's office asking if he could keep his $78,000 a year job.
Parents for and against Clark started e-mail and letter-writing campaigns to various state officials.
And the DDS Board and Clark began to test their newly reinforced authority.
During a phone conference in early May, Carmack told Fray that he would not be in favor of a special unit for mentally ill, violent and sexual predators. Fray had proposed that unit be started in September. Carmack said there wasn't enough money.
"We would do it tomorrow if we could find the money," Carmack said. "Even with the attorney general's opinion, we can't create money. It didn't come with a printing press."
In April 2001, Fray had signed a contract with UAMS to provide medical support for the Conway center.
In May 2002, Clark canceled a portion of that UAMS contract without consulting Fray. "I understand the UAMS contract was cut last week by $167,000," Fray e-mailed Clark on May 14. Clark responded that the rates for on-call doctors were $600 more per day than they were currently paying, and UAMS doctors didn't want to work nights and weekends.
Fray told Clark that he had since talked with UAMS, and "I was assured this morning by UAMS that they will honor their commitment to the Conway center regardless [of the funding cut]."
Fray continued to review outside professional contracts for the development centers. He refused to renew several of those contracts, citing high costs or the failure to comply with contract standards.
Knickrehm said that Carmack contacted DHS and said the board wanted Clark to remain at the Conway facility.
Carmack said he did not ask Knickrehm to keep Clark on. He said the DHS director may have misinterpreted what was said.
But Knickrehm said it was made clear to Carmack in mid-May that Clark would be leaving his job June 30 as planned.
Other things are changing at the Conway facility as well.
Fray's staff checked the files of seven other sexually aggressive residents at the request of the newspaper last week. One of the residents has moved.
While there are still problems with six others, the staff's increased awareness of the problem has dramatically cut the number of serious incidents.
"Staff had reported to me that the focus has expanded to not only work with the individual committing the act but also with the victims of sexual aggressors," Fray said.
The staff is developing a safety plan to teach residents who are sexually attacked how to respond and how to get away.
Meanwhile, relatives of residents from all the human development centers are worried that Clark's departure marks the inevitable closing of all the human development centers.
"There have not been serious discussions about closing the development centers," said Joe Quinn, DHS spokesman. "There have been informal discussions about whether we need as many development centers as we have.
"But is this department considering closing institutions? No. That is a major policy decision that would be made by parents and elected offcials."
Malone is adamant that parents not panic.
"The human development centers are not in jeopardy," he said. "We have consistently said we have to have a place in this state to take care of that vulnerable population.
"We will not rest until we have all the facilities doing the very best job possible," Malone said. "But closing them is not an option."
Editor's note: Two weeks ago the Conway Human Development Center received its seventh citation from the Office of Long Term Care for failure to protect its residents.
Deputy Editor Frank Fellone supervised this series.
MONDAY:
''Discourteous Treatment'' - or abuse?
Research assistance for this series was provided by Brenda Looper, Dauphne Trenholm, Angie Young and Chris Spencer.
Series editors include J.J.
Thompson, Bill Simmons, Griffin Smith, Frank Fellone, Sandra Tyler and Denise Dorton.
Barry Arthur was the photo editor. Doug Grimsley and Matt Spence were page designers. Kirk Montgomery directed the graphics.
Photographers include Staton Breidenthal, Stephen Thornton, Karen E. Segrave and Benjamin Krain.
More information
Information about events or incidents mentioned in this article is available by calling the Arkansas Department of Human Services at (501) 682-8677. Starting at 8 a.m. Monday, DHS officials will be available specifically to answer questions about operations at any state Human Development Center.
Department officials also will make available any public-record documents, such as those generated by state and federal investigations. Families of residents at the development centers also may receive documents relating to their specific family members.
The Arkansas Disability Rights Center Inc. - a federally funded, nonprofit agency - is a protection and advocacy agency for people with disabilities in Arkansas. It investigates complaints of abuse and neglect. Its 24-hour number is (800) 482-1174.
Copyright © 2002, Arkansas Democrat-Gazette, Inc. All rights reserved.