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GREENSBORO — One worker played the "tripping game" with his mentally ill clients. Another staffer used belts and hangers to smack a troubled teenager. And still another allowed a 16-year-old girl with bipolar disorder to wander through a local park unsupervised.

The girl got into a car with two men and was later raped.

All three incidents happened at Guilford County group homes for the mentally ill that were founded in the past five years and described in reports by investigators with the state's Division of Health Service Regulations.

They are some of the unforeseen consequences of the state's efforts to remake its mental health safety net, which have relied heavily on newly formed private companies to care for some of the state's most vulnerable residents.

"I don't want to take away from the new players who do a good job," said Melissa Floyd Taylor, a professor at UNCG's School of Social Work who has studied the mental health care system. "But not everyone who has gotten into this business since mental health reform did so because they had a true love or a true ability to meet the needs of clients. Some of them thought of it as an easy way to make money."

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When the General Assembly ordered the changes broadly known as mental health reform in 2001, it created a huge demand for private companies to provide housing and treatment for people with psychiatric problems. In response, hundreds of mental health companies began doing business across the state.

No fewer than 75 companies that now serve clients in Guilford County cropped up from 2002 through 2006.

Among Guilford County facilities licensed to house those with mental illness or developmental disabilities, there were 14 cases in 2007 where regulators determined the facility's actions either led or could have led to a serious injury.

That compares with eight incidents in 2006, seven in 2005 and three in 2004.

It's unclear what caused the increase in reports, although the rush of relatively new providers into the system seems to have played a part. Roughly three-quarters of those citations went to homes founded in the past five years.

Long-time players in the system say some of those new companies provide excellent care. But some have earned the attention of mental health regulators for all the wrong reasons. Additional examples include group homes cited for:

* Inadequate smoke detectors and other building code violations related to fire safety.

* An operator living in the house with her daughter, which is not allowed. The daughter got into a fight and hit a client.

* Inadequate staffing levels that allowed a patient diagnosed with autism and obsessive compulsive disorder to harass and sometimes spank other clients.

* Admitting a client with a history of being "sexually aggressive" without notifying staff or training them to deal with such a client. That person "inappropriately touched" two other clients in the home.

State and county regulators also found numerous instances of providers failing to properly train and perform criminal background checks on their staff and failing to properly document treatment.

Long-time players say new requirements should help weed out some lesser-qualified providers. In the meantime, the systems' problems emerge one client's story at a time.

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Jessica, a 16-year-old with a diagnosis of bipolar disorder and problems with drugs and alcohol, was ready to leave the hospital in early April 2007, but mental health workers struggled to find a group home with room for her, according to her grandmother and legal guardian, Nellie.

(Jessica's and Nellie's names have been changed to protect the teenager's privacy.)

Finally, she landed a spot at the Vida Group Home run by EZCare Providers, founded in 2004 by Richmond Okoro. The small, one-story house with yellow siding is similar to the other houses on Scotney Drive in southwest Greensboro.

Soon thereafter, on a Sunday afternoon outing at nearby Oka T. Hester Park, a worker from the home allowed Jessica and another girl to walk unsupervised, despite Jessica's history of ditching supervision of all kinds. The girls struck up a conversation with two men, who invited them to their apartment to get drunk.

The girls declined at first, but eventually Jessica got in the car with the two men.

Later that day, Jessica sat on the porch at the men's apartment. They asked her to have sex with them. She refused and tried to leave.

But the two men dragged her into a bedroom and raped her. She was eventually allowed to leave and stopped by an old boyfriend's apartment. Finally, she reunited with her grandmother and went to the hospital.

"I'm telling you, the parts of her body, the way they were bruised, there is no way under God's green earth any woman would allow any man during sex to do that to her body," Nellie said.

Jessica soon returned to EZCare. In June, Nellie said, Jessica spotted one of the men who had raped her across the street from the house. Workers at the group home would not let her call police, but Jessica called family members who did. The police responded and did take the man aside, asking Jessica to identify him.

"Well, Mr. Okoro got wind that the police were over there talking to Jessica, he called over here demanding I go get her and take her out of his group home, that I was causing him too many problems," Nellie said.

A few days later, Jessica moved to another group home.

Okoro did not return repeated phone calls seeking comment for this story.

But Nellie's account of what happened was confirmed in large part by documents obtained from state and county investigators and police reports.

No one has been charged in connection with the rape, Nellie said. A police spokesman refused to comment, citing policies that don't allow police to identify sexual assault victims.

As for EZCare, the state has suspended its license, but the group could be allowed to operate again after paying fines and submitting a "plan of correction."

"But that could change based on the issues the (state) has identified," said Alexis Underwood, a staffer at the Guilford Center who oversees local licensing of providers. "Those findings sent a red flag and alerted us."

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Underwood said he could not be more definitive about EZCare's fate because of the legal process. While the state licenses facilities like group homes, local agencies such as the Guilford Center "endorse" them. This push-and-pull does not always lead to rapid resolutions or even agreement among agencies.

For example, the Robbins Group Home in Jamestown is run by Wes Care Professional Services, which incorporated in 2002.

State regulators this year investigated that home in connection with a complaint lodged on behalf of a client from CenterPoint Human Services, the mental health agency for Forsyth, Stokes and Davie counties.

Regulators cited a number of violations, such as failing to properly train staff. A state report also details incidents when a teenage client was smacked with a belt and hangers.

Quoting from one interview with a client, the report says a staff member " 'told [client #4] that you know your mom gave me permission to whip you.' "

Eric Page, listed as the contact for Wes Care, did not return phone calls seeking comment.

The company was fined and ordered to file a plan of correction.

"I would have wanted a more severe outcome," said Grace Salgado, who oversees complaints about mental health agencies for the Guilford Center. "This is definitely a bad decision on the provider's part. If I was in charge, I'd close them down."

Although the Guilford Center could withdraw its endorsement, cutting off some clients, a license revocation would shut the agency down.

"I think they need to do a better job of cleaning house," Salgado said of the state.

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The EZCare and Robbins Group Home cases are stark examples of what can happen when inexperienced or undertrained workers deal with difficult clients. Less clear is how typical these types of problems are or how likely they are to continue.

The Guilford Center provided dozens of complaint records about mental health agencies logged in 2006 and 2007.

Some complaints involve responsiveness or other quality issues. Some complaints reflect difficulty getting needed medication or target the attitude of a particular worker.

"The complaints we get are more of that nature, complaints about the quality of care," said Ronda Outlaw, an administrator with CenterPoint.

She said more serious problems that threaten physical harm are infrequent.

Mike Moseley, who runs the state's Division of Mental Health, could not address specific cases such as EZ Care or the Robbins Group Home. In fact, group home licenses are overseen in large part by a different division of the Department of Health and Human Services.

Asked what it takes to revoke a provider's license, Moseley said the answer is not a simple one.

"I can't give you a hard-and-fast answer, but I will say to you that there have been providers who have been terminated from the Medicaid program," he said. "It's based on the nature of the situation and the severity of the problem."

Regulators have focused much of their attention this year on Community Support Service providers, which are supposed to coordinate care for clients. After audits during the past year, some of these agencies have been ordered to repay thousands of dollars because they could not properly account for the treatment they claim consumers got.

Although some community support agencies are owned by the same companies as group homes, records requested by the News & Record did not show they had committed the kind of life-threatening violations cited in this story.

Moseley said standards are getting tighter for all providers. For example, agencies will be required to seek national accreditation to get reimbursed by the state.

"A lot of the auditing we're doing right now is going to shake some providers out of the process," Moseley said. "We need providers, we need to make sure there is consumer choice. But we're not going to prop people up just to keep them in the program."

Contact Mark Binker at (919) 832-5549 or mbinker@news-record.com