Nearly a year before two young man died of fentanyl overdoses in houses operated by the Step by Step Recovery Home Society, the B.C. Health Ministry had investigated and substantiated complaints that it was failing to meet the most basic standards.
Within nine days of each other in December 2018, 21-one-year-old Zachary Plett and an unnamed, 35-year-old died in different houses operated by the non-profit society that has a total of five houses in Surrey.
A month earlier, inspectors had substantiated complaints at all five houses. According to the ministry’s assisted living registry website, none met the most basic standard of providing residents with safe and nutritious food.
None had staff and volunteers with the skills or qualifications needed to do their jobs. There was no counselling support for residents at any of the houses or any transitional help for those who were leaving.
Late last week, Step by Step closed its house at 132nd Street where Zach died. In a brief conversation Thursday, director Deborah Johnson said it was done “voluntarily.” She promised to call back after speaking to the other directors and staff. But that call didn’t come.
Late Thursday, a spokesperson for the Addictions Ministry said the assisted living registrar was aware that two Step by Step houses had been voluntarily closed, but was still attempting to confirm the closures.
Up until May, Step by Step had taken action on only one of the 65 substantiated complaints. It got rid of the mice at its house at 8058-138A Street in November. But it took 18 days from the time the inspectors were there before the exterminators arrived.
Despite all that, all five houses have maintained their spots on the government’s registry.
What that means is that the social development ministry has continued paying $30.90 a day for each of the 45 residents who are on welfare.
It also means that anyone ordered by the court to go to an addictions recovery house as part of their probation can be sent there.
In late May, Plett’s mother and others filed more complaints about Step by Step that have yet to be posted. But a spokesperson for the mental health and addictions ministry confirmed that they are being investigated.
Plett is incredulous. “My son died there and nothing’s been done,” she said this week.
In an email, the ministry spokesperson confirmed that no enforcement action has been taken and that there is no specific timeline for the investigation to be completed.
“The review of complaints is a complex issue that can often involve a number of agencies conducting their own investigations (which can also require a staged process),” she wrote.
“Each case is different and requires appropriate due diligence. Throughout the process of addressing non-compliance, as operators shift and improve the way they provide service, new assessments are conducted and status is updated online within 30 days.”
A senseless death
Two days after Zach Plett arrived at 9310-132nd Street in Surrey, he was dead. According to the coroner, he died between 9 a.m. and noon on Dec. 15, 2018. But his body wasn’t discovered until 4 p.m.
Plett described what she saw when went to collect Zach’s belongings.
“The house was horrible. The walls were dirty. The ceiling was stained. My son’s bed sheets were mouldy.
“His body was already taken. But the bed was soaking wet with his bodily fluids. There was graffiti on the furniture. The drape was just a hanging blanket. It was filthy.”
To add insult to grief and despair, Plett noticed that his roommate was wearing Zach’s shoes.
Worse than the state of house is the fact that Zach died in the daytime and it was at least four hours before anybody noticed.
Plett wants to know why nobody had checked on Zach? Were there no structured programs where his absence would have been noticed? Didn’t anyone wonder why he missed breakfast and lunch?
“I had no idea what it was like or I would never have sent him,” said Plett.
After battling addiction for seven years, Zach had spent the previous three months in Gimli, Man. and what Plett describes as an excellent facility that cost $40,000.
But Zach wanted to come home, despite Plett’s concerns about omnipresent fentanyl in Metro Vancouver. They agreed that he couldn’t live with her.
A trusted friend gave Plett the name of a recovery house and within a week of returning to British Columbia, Zach went to Into Action’s house in Surrey. It is a government-registered facility that has never had a substantiated complaint against it.
Because he wasn’t on welfare, his mother E-transferred $950 to Into Action to cover his first month’s stay. She was told that the staff would help Zach do the paperwork to get him on the welfare roll.
Later that day, Zach called his mother, asking her to bring him a clean blanket and pillow because the house was dirty.
Because family members aren’t allowed into the house, Plett met him at the end of the driveway to hand over the bedding. It was the last time she saw Zach.
The next day, Dec. 13, he called to say that he had been “kicked out” for “causing problems.” He told Plett that it was because he’d complained about the house and asked to see the consent form that he’d signed.
Later that day, someone from Into Action drove Zach to Step by Step’s house on 132nd Street. Two days later, he was dead.
Because of the confidentiality clause in the informed consent forms signed by all residents, Into Action executive director Chris Burwash would not even confirm that Zach had been a resident.
But he said before signing those forms, residents are given “a clear outline of the expectations of them” and “a clear description of what the rules are.”
They are told that there are no second chances if they break the rules.
“If they outright refuse to participate or outright breach our zero tolerance policies — violence or threats of violence, using illicit substances, intentional damage to facility, etc. — we are put in a position where it is impossible for us to allow them to stay. We have to ask them to leave,” he said.
Staff provide them with a list of other government-registered recovery houses and sit with them while they make their choice without any advice or interference, Burwash said. Once a place is found, Into Action staff will take them there.
Burwash emphasized that only registered recovery houses are on the list, which speaks to the importance of the governments registry. But he said it’s frustrating that operators don’t comply with registry standards since their failures reflects badly on all recovery houses.
“We absolutely support the media shining a light on the facilities that are operating below the standards that they agreed to abide by,” he said. “We are certainly not one of them.”
He invited me to visit any time.
On Dec. 14, Zach and his roommate went to an evening Narcotics Anonymous meeting. Plett found the sign-in sheet from the meeting when she collecting his belongings the following day.
“What he and Billy (his roommate) did between then and early morning, I don’t know,” she said. But another resident told her that she thought they were “using” until around 5 a.m.
The toxicology report from the coroner indicated that the amount of fentanyl found in his system was no more than what is given cancer patients for pain control. But because Zach hadn’t taken opioids for six months, his tolerance for fentanyl was minimal.
“Had he died in the middle of the night, I would never have gone public with his story. But he died in the daytime. If they’d woken him up for breakfast or tried … ” said Plett, leaving the rest unspoken.
“He wasn’t monitored. He wasn’t watched … If I had known I would never have sent him there.”
Last week, Plett had an hour-long meeting with Addictions Minister Judy Darcy and the mother of the other young man who overdosed. He died Christmas Eve at another Step by Step. His body was only discovered on Dec. 26 after other residents kicked in the door of the bathroom where he was locked inside.
“She (Darcy) was very genuine and sympathetic,” Plett said. “I don’t think she realized how bad the situation is.”
Problems left unresolved
Step by Step’s first non-compliance reports date back to an inspection done Jan. 23, 2018 at its house at 11854-97A Street in Surrey.
Inspectors found that meals were neither safely prepared nor nutritious. Staffing didn’t meet the residents’ needs. Staff and volunteers weren’t qualified, capable or knowledgeable.
On Nov. 2, they returned. Nothing had changed and more problems were found.
The house didn’t safely accommodate the needs of residents and staff. Site management wasn’t adequate. There was no support for people transitioning out of the residence.
Critically, there were no psychosocial supports to assist individuals to work toward long-term recovery, maximized self-sufficiency, enhanced quality of life and reintegration into the community. Those supports include things like counselling, education, group therapy and individual sessions with psychologists, social workers, peer-support counsellors or others with specialized training.
On Feb. 4 and March 27, inspectors went back again because of a fresh set of complaints. As of May 8, none of the substantiated complaints had been addressed.
On the same day in November that inspectors were at the 97A Street house, they also went to Step by Step’s other four houses in Surrey — 132nd Street where Zach Plett died, 78A Avenue where the other man died, 13210-89th Avenue and 8058 138A Street. Step by Step doesn’t own any of the houses, but one of it directors, Deborah Johnson, is listed as the owner of 138A Street.
Not every house had the same complaints. But all of the complaints were substantiated and there were commonalities.
None had provided properly prepared nutritious food. None had adequate, knowledgeable or capable staff. Not one house was suitable for its use.
None supported residents’ transition to other accommodation or provided psychosocial support.
Since then, there have been repeated inspectors’ visits but the last posted reports indicate that nothing has change.
The first of five guiding principles for the province’s assisted living registry is protecting the health and safety of residents. Promoting client-centred services is also on the list. But then it gets a bit fuzzy.
Others are to “investigate complaints using an incremental, remedial approach” and to “value the perspectives of stakeholders — i.e. residents and their families/caregivers, community advocates for seniors and people with mental health and substance use problems, residents, operators, health authorities and other agencies.”
But as a result of this incremental, remedial approach and seeking of stakeholders’ perspectives, there were two preventable deaths.
What more do inspectors need before the registration for these five houses is cancelled? How much more time will the province give Step by Step to bring them into compliance?
And, how much longer will the ministry of social development continue writing cheques of close to $42,000 each month to an organization that can’t even comply with the most basic standards?
British Columbia is four years into a public health emergencies that has cost 4,483 lives since a public health emergency was declared in 2016.
More than a year ago, a coroner’s death review urged better regulation, evaluation and monitoring of both public and private treatment facilities following the 2016 overdose death of a 20-year-old in a Powell River recovery house.
It’s unconscionable that the government continues to waste precious resources on substandard recovery houses, while doing so little to force bad operators into compliance. At a time when good quality services are more desperately needed than ever, the registry ought to be the place that vulnerable addicts and their loved ones can find those.
Until this is fixed, Maggie Plett is likely right to believe that Zach would have been better off homeless. At least on the street, someone might have noticed him and done something to help.