The Echo

Eight homes were found deficient in having consistent fire drills. Seven homes were found deficient in having complete first aid kits.Five homes had multiple throw rugs that had no anti-slip coating on the back. Four homes had medication not appropriately secured. Three homes had expired fire extinguishers. Three homes had items within three feet of the hot water heater which is a fire hazard. Two homes had staff who did not know how to use the organization wide fire control system (one of them was the house manager).  In both cases. neither home had the key to turn off the alarm once it was activated.  Staff had to go to another house or the day program to obtain it.

Cathy Ficker Terrill is a professional. As she took on this latest assignment, Terrill knew she had to be unbiased. Her visits the Bellwether facilities were blind exercises. She waited until after she completed her visits before she reviewed the DHS annual licensure reports. Her results were not that far off. 
https://www.state.nj.us/humanservices/news/reports/BBH-Independent-Monitor-Report.pdf

Overview of Bellwether licensure reports on the 14 homes with provisional licenses 14 group homes were surveyed as follow up to provisional findings in licensure.  All 14 homes submitted Plans of Correction (POC) prior to the observation visit.  Of the 14 POCs submitted, 13 homes were found to have at least one instance in which something the POC stated as being taken care of had not, in fact, been taken care of.  All 14 homes received notations of items that were repeat deficiencies.  In four instances, repeat deficiencies were marked as “Two-time repeat deficiencies”.  Notably: 13 homes had repeat deficiencies in Physician Orders not being followed; 13 homes had repeat deficiencies in Behavior Support Plan (BSP) implementation and tracking; 11 homes had repeat deficiencies in documentation of incidents in Therap(y); 11 homes had repeat deficiencies in training documentation; 10 homes had repeat deficiencies in correct completion of the Medication Administration Record (MAR); and 10 homes had repeat deficiencies in issues regarding the physical plant of the home.

Other areas of repeat deficiencies found in multiple houses include completion of the critical incident log (six), completion of the emergency evacuation plan (EEP) (six), medical documentation (six), documentation of fire drills (three) and records storage (two) https://www.state.nj.us/humanservices/news/reports/BBH-Independent-Monitor-Report.pdf

 So what does all the gobblygook mean?

Facilities are required to maintain a Critical Incident Log. Ferrill found that in some cases the log was unavailable, incorrect, missing, or contained inconsistent entries. In thirteen homes she found that the staff had failed to perform required training of Behavior Support Plans (BSP) - a tool absolutely necessary in providing individualized and appropriate care to clients with behavioral needs.  Ten homes couldn't provide adequate documentation of staff training for BSPs, adaptive equipment, and specialized needs. 

At least nine homes had medication tracking errors  (MAR - Medication Administrative Records.) The question the lay man asks - did residents receive prescribed medication in manner prescribed by their doctors? 

Ferrill found that many Bellwether facilities were simply bereft of the correct paperwork necessary to operate a residence or day setting for those with developmental disabilities. There's an old saying amongst those who work in the medical community especially areas that are highly regulated like Bellwether, "If it wasn't written down, it didn't happen." This guidance swings both ways - it can exonerate a facility or individual from unfounded allegations or become evidence that a facility or individual failed to follow the regulations. For Bellwether, it was the latter.

Gov. Murphy halted admissions to Bellwether Behavioral Health in July 2018. Subsequently, the Department of Human Services announced it would be appoint an independent monitor to evaluate the company and its facilities.

Cathy Ficker Terrill is a true bellwether in the field of intellectual and developmental disabilities. Described as compassionate and caring, she has experience serving in positions that improve the qualify of life for those with disabilities. She's a former CEO of the National Council on Quality and Leadership, which trains and accredits service providers to individuals with intellectual and developmental disabilities. Cathy is an international advocate, an university educator, and mentor. This description barely scratches the surface of her vast experience. New Jersey couldn't have chosen a better monitor.

May 22, 2019. It was a bellwether moment. Cathy Ficker Terrill released the Independent Monitor Report. She had travelled statewide, sometimes visiting sites multiple times. She structured her report around her findings in 10 randomly selected homes and five day programs, although ultimately, she visited all seven day programs. Her travels took her to Burlington, Gloucester, Pasaaic, Salem, and Somerset Counties.

And these were the trends that Cathy Ficker Terrill found (this excerpt is directly, word-for-word from IMR):

As part of this review, a simple trend analysis of DHS’ licensure reports for Bellwether from 2016, 2017 and 2018 was conducted.  The following trends were identified.  Although some work has been completed to improve conditions in homes (basic cleaning services, food labeling and completing maintenance orders) the analysis identified the following areas still need continued improvement:


• Lack of cleanliness of the homes;  
• Numerous medication errors of documentation and administration; 
•  Food not labeled, dated or identifiable in the freezer;  
• Outdated food with freezer burns;  
• Maintenance orders not completed in a timely fashion;  
• Knives not being locked in a house where it is a safety hazard;  
• Cleaning products not stored in a safe manner;   
• Staff schedules that are not current or accurate;  
• Lack of maintaining and updating critical log for daily events in each home;  
• Lack of training or retraining for staff on diabetes monitoring and care;  
• Lack of data on special diets;  
• Laundry products not stored in a safe manner;  
• Inadequate data reporting on behavior plans;  
• All staff did not have documented criminal background checks;  
• All staff were not documented through the central registry back ground checks; 
• Gaps in follow up from medical appointments;  
• Missing documentation on staff training specific to behavior support plans;  
• Physician orders not regularly individualized;  
• No system to delineate critical and non-critical information in electronic health records software;  
• Failure to document critical information;  
• Job descriptions were not current for staff;  
• Lack of documentation of training for staff;  
• There is not a consistent policy implemented for smoking in the home for individuals or staff;  
• Lack of implementation of a policy on maintenance and storage of individual records on the homes;  
• Several homes not in compliance with the local fire inspection requirements; and  Inconsistent human rights committee reviews.

Say it with cadence. The independent monitor report, the independent monitor report, the independent... with each syllable you begin to hear each nail as the hammer strikes its head and you hope the coffin will soon be sealed.

The NJ Department of Human Services was on the receiving end of a deluge of complaints. On August 9, 2018, Governor Phil Murphy halted new admissions to Bellwether Behavioral Health and "demanded 'immediate correction all concerns' involving safety and staffing shortages uncovered in 18 months of inspections." - http://connect.nj.com/staff/sklivio/posts.html

DHS had stopped referrals after WNYC aired a report about the Gordian knot at Bellwether's Branchburg group home. WNYC journalist Audrey Quinn provided a succinct update that clearly moved DHS. The four minute audio rush focused on the Saccoh family and the experiences of their loved one, Abdulaye. In 2012 Abdulaye was offered a community placement in a beautiful,clean home close to his family. Advoserv promised programming that would fits his needs - those of an adult with autism who loved gaming and Special Olympics. However, that wasn't what Abdulaye and the Saccoh family actually received. In his first year he lost 100 lbs and was anxious whenever family visited. The programming was invisible. Abdulaye presented with scratches and wounds including a broken clavicle that were blamed on other residents in the home. 

But, Abdullaye's story wasn't what spurred DHS to action. Yes, the family wanted to find a new home for him. But, his abuse was unsubstantiated... Until December of 2016 when Abdullaye was allegedly beaten by a staff member and hospitalized. The home's social worker called the Branchburg police to report the abuse. Even that wasn't really news and it barely passed muster for revoking admissions. 

It was this eye-catcher -

Bellwether homes in Somerset County drew 156 rescue squad called over two years, including seven involving employees accused of assaulting residents. Police are routinely called several times a day to intervene when staff is low... - Audrey Quinn

Between January of 2017 and May of 2018, NJ Advance Media combed hundreds of pages of Bellwether inspection reports. They found deficiencies such as rotting food, broken furniture, missing pillows, shower curtains and toilet paper. Perhaps more concerning were the med errors or medication mismanagement by the staff,  misuse of physical restraints and failing to document injuries. -https://www.nj.com/healthfit/2018/08/group_home_operator_for_disabled_will_get_no_new_a.html

When Abdullaye left his Branchburg home, he was transferred to another Bellwether site. However, according to the family as reported by Audrey Quinn, the abuse didn't end. An attorney from Disability Rights New Jersey helped convince the state to find a new home for Abdullaye. He was moved into emergency placement and nine months later is still there...highlighting the lack of placements available to those with developmental and behavioral disabilities. 

Abdullaye's story explains why Bellwether was able to get a foothold in New Jersey despite its record of abuse and neglect. The company managed to leverage itself for the title of largest group home provider in the State with 62 licensed facilities and 495 beds because of the tremendous need and lack of resources. Bellwether took advantage of another state with a fractured care system. And It took 18 months of both scheduled and surprise inspections and reports of abuse and neglect for NJ DHS to turn off the spigot of referrals and demand accountability - as much for the neglect and abuse - as it was for the fortune Bellwether was making off the citizens of the state through the Medicaid trough. To think, a hedge fund, generating value for its share holders while people were beaten, abused, neglected, and sometimes died. 

It was 2018. As part of their decision to put a moratorium on admissions, New Jersey moved to insert an independent monitor and to continue with random inspections. Bellwether was getting another chance. 

To NJ.com, spokesman Brian Burgess responded to the sanctions: 

Our primary concern is to ensure the health and safety of all the individuals entrusted to us and to provide quality care to these individuals, which is why we are working closely with the state officials to address all of their concerns.

Followers of the Bellwether saga might remember Brian Burgess, who in March 2017 emailed ProPublica reporter Heather Vogel the motivation for changing the name from Advoserv to Bellwether.

Over the past year, a completely new leadership team, with a different management philosophy, initiated a series of transformational changes designed to fundamentally alter the trajectory of the company. The new name - Bellwether Behavioral Health - is just an outward reflection of the fundamental changes designed to deliver better outcomes for the individuals in our care. https://www.propublica.org/article/bellwether-behavioral-health-is-controversial-group-home-operator-advoserv

At the time Burgess declined to disclose to Vogell how the company's operations and management philosophy were changing. Vogell noted that all but one of the top six executives listed on Bellwether's website had been hired in the last year. Currently, there is only one executive listed on the company's website. 

Burgess also made this statement in September 2018 after another allegation of abuse and a lawsuit surfaced in Florida:

However it is important to note that our team members at Carlton Palms are some of the most caring and compassionate professionals in the industry, all of whom work side-by-side with state officials to deliver the highest quality care possible while serving some of the most challenging individuals in the nation.  -https://www.orlandosentinel.com/news/orange-county/os-carlton-palms-closes-lawsuit-20180917-story.html

Echo's question? Were the Florida executives the most caring and compassionate?  Or do the six new executives in New Jersey get the honor of being the bellwether, the leader, the crusader, the change maker, the most caring and compassionate?

And where in bloody 'ell did these executives come from? It could be opined the Kizam School of Abuse and Neglect?  What we have read in these news accounts is that nothing actually changed from Florida to New Jersey other than the name of the business. Bellwether even kept up with the 911 charade to handle difficult residents and keep its personnel costs down. Why train staff when the police already have the experience?

A for-profit company that runs group homes for the developmentally and intellectually disabled has changed its name from AdvoServ to Bellwether Behavioral Health, following ProPublica articles on three teenagers’ deaths and staff’s frequent use of physical holds and mechanical restraint devices.  - Heather Vogel, ProPublica, March 28, 2017, https://www.propublica.org/article/bellwether-behavioral-health-is-controversial-group-home-operator-advoserv

Reporters in New Jersey cracked the code for an anomaly that occurred with tremendous frequency at Delaware's Advoserv/Bellwether's residences.

According to the Record, New Jersey officials have logged hundreds of 911 calls from homes owned by Bellwether. During early research, Echo found that in the old days, when the News Journal published fire calls, the Gingerbread House often had dozens if not more during the week.  Why? Why did a facility staffed by people supposedly trained to care for the most severely disabled need to call 911 so often?

Ringwood New Jersey Police Chief, Joseph Walker, explained in the Record expose that his office receives 911 calls from the four Bellwether homes in its jurisdiction at least four times per week. The most frequent request is for officers to restrain clients.  Walker urged officials for the residences to hire more experienced staff that could assist his officers.

This is the dilemma faced by police agencies responding to these 911 calls: HIPAA prevents first responders from knowing the diagnosis of the resident in crisis. Thus, responders enter the home without critical information that could inform how they deal with a particular client. Walker believes that better trained staffed would be an asset to his force when responding to these calls.


From January 2017 to March 2019, 10 homes and one day program in New Jersey made more than 360 911 calls according to NorthJersey.com and USA today. The Longhouse Dr. residence accounted for approximately 100 of those crisis calls. Often, police were informed first by concerned resident before the Bellwether facility responsible for that client contacted the police. On at least one instance, a helicopter search had to be performed in order to located a lost client.

Other police reports accuse Bellwether employees of speeding, being on drugs or alcohol while on
the job and possession of illegal substances. NorthJersey.com also found one incident in which a resident was left for 45 minutes on a van on day with temps that met or exceeded 93 degrees.

What concerns officers like Ringwood's Walker is that the townships rely on volunteers to staff their fire houses and ambulances. Some only have one ambulance. The Bellwether calls are burden that can be addressed without outside intervention if basic security measures were installed in homes and staff were properly trained.

But, Bellwether's lack of effort provides little hope to local departments.

And it reinforces a pattern started first in Delaware decades ago. Understaffed? Undertrained? Call 911. It's far cheaper for a care provider to call 911 than to train and staff facilities in a manner that ensures clients receive the proper and most appropriate interventions when needed.

Former employee, Edward "James" Boyle, filed a whistle blower lawsuit against Bellwether after his sudden termination in March. Prior to his separation from the company, Boyle, a home manager, became aware of a sexual assault of one client by another. Per state laws, he made the proper notifications. Bellwether, in turn, chastised him for notifying the victims guardian. He was let go shortly thereafter. Bellwether insists the termination was non-retaliatory, although the company provided an excuse for it's decision - Boyle had allegedly told staff at his previous home that they should not call 911 if a client was choking on food. According to the New Jersey record Boyle strongly disputes this claim. He also shares much more information about the status of the management of the New Jersey residences.

As a house manager, Boyle had a daunting job - ensuring his home was fully staff.  However, according to The Record, Bellwether often refused to provide the minimum number of employees to meet client needs. Boyle's home required 16 staff members, yet Bellwether only provided up to eight employees. Unable to leave his clients unattended, Boyle often spent the night or weekends at the home to ensure there was at least one adult present.

Boyle's account of staffing shortages was verified by a second employee who asked to remain anonymous due to a non-disclosure clause. However, this individual described arriving for work to find clients wandering about with no staff on site. Family members also echoed these sentiments. The truth was further confirmed by residents of the town of West Milford, who, in March, announced they were being "terrorized" by residents of a nearby residence. According to the New Jersey Record, residents recounted how in the previous November in the middle of the night, a naked man broke four garage windows, damaged a door, and tried to rip out a lighting fixture in his effort to break into a home located near his residence. In March the same Bellwether client was found in the neighboring community slamming his body into a door in an effort to gain entry. When the resident tried to intervene, the client turned violent. A similar incident recently occurred.  The frequent interruptions have caused many homeowners to invest in home security camera systems. At least one family intends to sue Bellwether; another home owner has security camera footage of a resident during a nighttime elopement.
https://www.northjersey.com/story/news/passaic/west-milford/2019/03/22/west-milford-neighborhood-terrorized-escaped-bellwether-group-home-patients/3222467002/

(Pardon the underline. Sometimes Echo has a mind of her own. Perhaps it's because she can see into the past or perhaps b/c her A.I. has achieved humanity.)

"Criminal background checks were not documented for all Bellwether staff..." 

And this is just another simply sad truth, another notch their belt for Bellwether and the organization from which it was borne, Advoserv and Au Clair.