This editorial appears in the Feb. 7, 2010, Yakima Herald-Republic.

When Nadra McSherry died in 2006, a doctor said the heart attack that killed her resulted from an infection caused by a quarter-size bedsore that opened all the way down to her tailbone. Her death may have been preventable had the owner of the Tacoma adult family home where McSherry lived provided proper care. The state Department of Health and Social Services fined the home's owner, Arlie Leno, $100 for each of the 32 days that he failed to provide that care.

What else did DSHS do? Nothing. It didn't revoke Leno's license. It didn't record McSherry's death in its computer along with violations at the group home. And it continued to allow Leno to operate Narrows View Manor despite repeated serious violations afterward and despite recommendations from DSHS field staff to yank his license.

The story of McSherry's death and indifference in the higher reaches of DSHS toward it was one of the most shocking revelations of a Seattle Times series of articles last week on the adult family-home industry in Washington. The newspaper and reporter Michael Berens crunched data from 15 years' worth of inspection reports to show how thousands of adults, most of them frail in mind or body, have been neglected or abused.

The newspaper reported it "uncovered accounts of elderly victims who were imprisoned in their rooms, roped into their beds at night, strapped to chairs during the day so they wouldn't wander off, drugged into submission or left without proper medical treatment for weeks."

In some cases, not only were staff improperly trained, the owners hired staff who should have been barred because they had felony convictions.

While the state says the majority of adult-home operators do a good job, it's clear that more and better oversight is needed, that the paltry penalties for violations must be strengthened and that the owners and their employees need more training.

There are more than 2,800 adult family homes in the state providing care to about 11,200 people. About a third of the residents don't have enough money to pay for their care; Medicaid pays their bills, with the state and federal governments splitting the cost. Most of the remaining residents pay their own way, primarily so they can live in a home-like setting rather than the more antiseptic environment of a nursing home.

These are our parents. Our husbands, wives and other loved ones. Our children.

The state started licensing people to provide care in their homes 20 years ago and has encouraged their growth ever since by imposing few regulations. In cases where Medicaid pays the bills, state government stands to benefit because the tax-supported costs of caring for someone in an adult family home are about one-third of what the state would pay to a nursing home.

But no one benefits -- except those adult family-home owners who hope to wrestle every dollar of profit from their enterprises -- when standards of care are ignored and the state turns a blind eye toward it.

Responding to the Times' series, Gov. Chris Gregoire ordered DSHS to fully review how it polices the adult family home industry.

DSHS Secretary Susan Dreyfus immediately announced several reforms. Among them: requiring adult family home owners to post investigative reports on site; publishing its investigations on the agency's Web site; and conducting interviews with all residents, not just a select few, when the agency does its inspections.

Dreyfus noted that the agency has installed a new computer system in the last year to track enforcement actions. And she'll comply with Gregoire's charge to look into how adult-family homes are sold in light of revelations that some owners in the Puget Sound area have marketed their properties as including residents being part of the sales price.

Louise Ryan, the state's long-term care ombudsman, supports the changes but notes they are "just a start." The Washington Residential Care Council, which represents owners, also supports the changes.

One lawmaker, Rep. Mike Armstrong, R-Wenatchee, has proposed splitting DSHS into four new agencies. He called attention last week to both the adult family home problems and other recent reports of neglect involving children.

The gargantuan DSHS is an agency frequently in the hot seat. Fix one problem, and it seems another one pops up. We're not prepared to say Armstrong is on target -- his proposal could be more costly and result in even more bureaucracy. But what we are sure of is that the ball's in the governor's court and the Legislature's to hold the agency accountable and make sure DSHS makes good on its promise to strengthen oversight of the adult family-home industry.

* Members of the Yakima Herald-Republic editorial board are Michael Shepard, Bob Crider, Spencer Hatton and Karen Troianello.