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The 911 Mystery Solved

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.

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The Whistleblower

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/




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The Irony of an Idyllic Paradise is that it isn't Paradise at all.



(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.)









Therefore it seems almost grotesque that Advoserv would purchase a property that is defined by the borders of a state that has deemed their violations so severe it banned sending it's children and adults there due a documented elevated risk for abuse and neglect. It not an idyllic paradise, but a scene from a horror novel. 

On May 19, 2017, almost seven years to the day Somerville Llc/Advoserv settled on the property, the Beltre family is notified that their beloved brother, Carlos, a resident of the home has stopped breathing. His family has engaged Bellwether in litigation. His death is a bit of a mystery. 


Part II: Featherstone - Too absurd to be real...

Sometimes, the stories Echo unearths are too absurd to be true. 

Like children being held hostage from their families 
or
A care providers driving all six of her residents to her court hearing about her suspended drivers license. 

Simply, sadly, true.



PART II
Entire Account as presented by: , North Jersey Record Published 10:12 a.m. ET June 27, 2019


End Account


In our search, Echo found that, Featherstone has accumulated the following charges:
Code39:3-40
DescriptionDRIVING ON THE REVOKED LIST
Code2C:29-3B(4)
DescriptionHINDERING-ONESELF-GIVE FALSE INFORMATION
Code 2C:28-4A
Description FALSE REPORTS TO LAW ENFORCMNT-FLSLY INCRIM OTR
Echo hasn't found the record of the disposition of these charges to date. They may have been pled down, thrown out, found innocent or guilty, time served, freed, etc. Yet, we now know that some one lacking the legal confidence to drive put loved ones on a van and gave them a tour of the judicial system. Echo has been unable to cull from online files why Featherstone had her license suspended initially. However arrest records for a similar looking Yaeesha Shavonne Featherstone date back to at least 2016. If one and the same, Bellwether may be culpable, in our opinion, in performing inadequate background checks. The North Jersey Record agrees, 
"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.


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Part I. Too Absurd to Be True...But They Are

Sometimes, the stories Echo unearths are too absurd to be true. 

Like children being held hostage from their families 
or
Care providers driving all six of her residents to her court hearing about her suspended drivers license. 

Yet, they simply, sadly, are true.

Part One
Despite the compulsion to summarize the insanity of this story, there is no more adequate persuasion than presented by the original author, Jan Hefler. Therefore, I have posted the entire document, Bruce Jackson, victim Sun, Aug 1, 2010 – Page A01 · The Philadelphia Inquirer (Philadelphia, Pennsylvania) · Newspapers.com

Off the bat, I can tell you that there is no suitable follow-up to the story presented below. The significance of the story was the impact it made on New Jersey Social Services. What happened in Bruce Jackson's adopted home was the second such discovery that year and spurred change across the system. The same system that oversaw Advoserv. Was/Is that change better? I don't know enough to tell you. Perhaps our New Jersey readers will weigh in.

The purpose for its inclusion in this series of posts is the role played by Advoserv who became Bruce's caregiver after he was placed in one of their homes. What you are about to read lends to our story the fact that Advoserv personnel or the company itself denied Bruce's adopted brothers access to him. These young men considered Bruce their hero for freeing them of the hell in which they were living. Yet, the state and his care facility, pushed back to keep Bruce behind a veil and deny him the very family that the same agency had created for him when they repeatedly adopted sons to the Jackson parents.


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What really happened at Bellwether New Jersey

There is a distinct difference from what Bellwether promised the State of New Jersey, it's residents with disabilities and the families who had cared for them the day their child received her first diagnosis. While stories of satisfaction do exist, Bellwether couldn't maintain the staffing to ensure quality in all of its 60 plus facilities.

On June 27th, the New Jersey Record revealed detailed confirmed accounts of abuse cited in State inspections and reviews of the companies community facilities. It was dark.
https://www.app.com/story/news/investigations/watchdog/2019/06/27/bellwether-behavioral-health-group-home-nj-failed-while-collecting-taxpayer-money/1582291001/?fbclid=IwAR0QUbZ74wl3Pe92Gii2EAWaR9-AOCtvbub-cl9E5WuzXbsb9epRt3S2Qsg

What follows is an abbreviated account of the violations documented and confirmed by reporters Kim Mullford, Gene Meyers, Lindy Washburn, and David M. Zimmer. Thank you for your thoroughness and attentiveness to the needs of those without a voice. 

The state found:
  • In Susan's Osborne's chart, it was clearly indicated that her meals be cut into small bites and be observed by staff her during meals so that "she wouldn't stuff her mouth swallow too quickly." These were medical orders entered into Susan's care plan by HER DOCTOR. It didn't make sense that a staff member would neglect these orders. Nonetheless, Susan died May 30th after choking on her meal. It's alleged that three staff members immediately moved to cover-up the cause of her death. A lawsuit filed by Susan's guardians paints a grim picture of her death, the cover-up, and finally the admission from staff that they had not followed her doctor's orders. Bellwether is named in the suit; their response is to blame to the employees. BLAME THE EMPLOYEES? Bellwether hired the EMPLOYEES. Bellwether trained the EMPLOYEES. Susan's death is a shared preventable tragedy for which Bellwether should accept ownership of due to their failure to ensure her safety and care. 
  • Joshua Hays was another resident in Susan's home. At 24, he was challenged by autism and pica. In 2016, Joshua needed surgery to remove indigestible items, including balloons and rubber gloves that he had eaten as a result of his pica. Bellwether, then known as Advoserv, assigned employees to the hospital to observe Joshua's recovery from surgery. During his first 36 hours under the oversight of his "observer," he removed and ingested his abdominal bandages. According to court records, the family settled its lawsuit for $575,000.
  • In May 2017, Carlos Beltre died under what his family felt where mysterious circumstances. His sisters had noticed that Carlos often had injuries during visitation - a split lip, a black eye, and cuts that had been stitched at the hospital. On May 17, one of his sisters received a call that he had stopped breathing. His death certificate states he died from an irregular heartbeat of unknown cause - while in the direct sight of staff. The family is currently litigating the events that led to Carlos's death.
  • A few days later, in another home, Francesca Gregorio, got up in the middle of the night in search of something to eat. The kitchen cabinets were supposed to be locked and Francesca was supposed to be supervised. However, she found an open cabinet and drank a bottle of oven cleaner. After the initial agony, she fell into a coma at the hospital. She's now a resident of a rehabilitation facility where she receives all of her nutrition through a feeding tube. She can no longer walk.
  • In Gloucester County, Lauren Page was punched in the face by a staff member. She had to have surgery to repair her broken eye socket. The employee pled guilty to assault and was placed on 1 year probation. Lauren now suffers from PTSD. 
  • Nicholas Mayer had autism. At a doctor's appointment with his mother, she notices scratches and similar injuries. Nicholas told her that they were from being restrained. When his mother investigated, she found the staff had a code word they used to get Nicholas worked up so that they could restrain him. She reported what she learned to the state. The state confirmed the assertion. 
Next Up: The New Jersey Record Reporters delve deeper.




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What was Bellwether supposed to provide? The easy explanation.


This is what Bellwether advertised as their strength: Skimming the children and adults who received the higher rate of reimbursement because of the need to add additional staff to manage them. Only, the staff simply didn't exist. Yet, the homes had to operate. PEOPLE lived there. They were after all HOME to each of the residents. And despite Bellwether's demise, most residents will continue to call these facilities home as outside operators are moving to take over management and staffing of these homes. 

What no one has addressed is how to undue what happened to those residents who lived in facilities that repeatedly failed them. Or how to prevent it AGAIN. Florida, Delaware, New Jersey. 

The legacy continued. By year three Bellwether business in the Garden State was falling to pieces. 


What services did Bellwether Provide?

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New Jersey closing its doors to Bellwether

What ever happened to Bellwether/Advoserv/Carlton Palms? I've heard that question often over the last year. From advocacy groups to parent groups, they wonder why the Gingerbread House closed up overnight and went up for sale. Bought by a builder in Delaware, the house will likely stay, but the grounds are in growing residential area where McMansions don't dot the countryside, they are the countryside. 

While Bellwether left Delaware and Florida in a quiet rush, it had already set down roots in New Jersey.

Things didn't go well.

New Jersey was a state with a vast deficit in community based living options. It had been a mandate of the federal government to start moving institutional-based of individuals with developmental disabilities into their communities. Community-based living was a concept that eventually was determined to be a best practice. This required a wide range of homes to meet the needs of varying disabilities. Families who had been over-burdened by the depth of their child's disabilities where also hopeful that a community based setting would help relieve the pressure they bore while improving the quality of life of their loved one. 

In all Bellwether would accumulate 62 homes. However, in New Jersey Bellwether found it harder to play ball. It may have accumulated more homes than any other service provided; however, the company didn't have Ken Mazik's political savvy. Whereas he had deftly handled politicians and moved legislation along to support for-profit homes and to hide deficiencies, Bellwether was simply unable to court policy makers. And I suppose you can only hide so many deaths and accusations of abuse for so long...



On May 28, 2019, Tom Hester, a spokesperson for the State Department of Human Services announced that 9 different operators would assume Bellwether's facilities, residential, and day programs. While residents would not have to re-locate, Bellwether was going into receivership after being unable to sell itself. It was crashing...hard.

Furthermore, there is no guarantee that all of these 9 providers will provide better care. That's due to the enormous staffing shortage. Who wants to work with developmental and intellectually disabled adults when their salary is $11/hour? It's rewarding but exhausting and that pay doesn't always attract the best candidates for the job. It's a national crisis.  



NJ Doors ClosedNJ Doors Closed Tue, May 28, 2019 – A2 · Courier-Post (Camden, New Jersey) · Newspapers.com


Staff Shortage in New Jersey
Staff Shortage in New Jersey Tue, May 28, 2019 – A2 · Courier-Post (Camden, New Jersey) · Newspapers.com
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The Tribute to Paige

I had planned to close this blog with a bio of each child or adult identified as dying while in Bellwether's care. When a hedge fund buys a for-profit mental health system, it inherits it's debts, losses, and deaths. The stain transfers one owner to another, although that does not exculpate Ken Mazik's role in the nightmare conditions of the beast he created and from which enriched himself.

Prince Jon was the first known death.

Paige Elizabeth Lunsford
Florida, July 6, 2013

On July 6, 2013, Paige Elizabeth Lunsford died while in the care of Carlton Palms. The story of her death would be recounted in the press multiple times. It was her death that might have put the wheels of closure in motion.

In the days prior to her death, Paige Lunsford vomited "like a waterfall" according to a supervisor at Carlton Palms where the 14 year old with autism resided.

Yet, Paige didn't receive proper medical care or the potentially live saving trek to the Emergency Room at her nearest hospital until she was dead. Her official cause of death was medical neglect and inadequate supervision. That's are far cry from what her death entailed.

"For five days and five nights, Paige Elizabeth Lunsford... wretched like a waterfall, could not eat, and thrashed about in an educational facility staffed with teachers, nurses, and doctors."
Paige's condition was not improving, yet no one called for help. Instead the young teen was placed in restraints, they bound her wrists, ankles, biceps, and waist to try to control her thrashing.  Ten days after Paige was admitted she died of a high fever. The coroner noted that she was severely dehydrated due to an infection - a condition that could have been treated and did not need to end in death. Where was the nurse? Where was the doctor? Why did no one come to Paige's aid as the young girl was strapped into a her death bed? Why did her parents not know how sick she was? They'd delivered a health teen just 10 days prior and Paige was a minor!

At 7 am, July 6th, 2013, Paige's suffering came to an end 
when she went into full cardiac arrest.  


Paige's death became the 140th complaint lodged against Carlton Palms and it's owner AdvoServ in Florida. The investigation into her death found that all but one hour of video surveillance of the child's final day was accidentally deleted. What detectives did see in that one hour was mundane and unremarkable. Paige herself was known to be self injurious. She came to the Palms with a helmet, special arm splints and special clothing to help keep the child from excessively scratching herself. Her medical records notes that her behavior would escalate if she was sick or in pain. When that happened, staff put her restraints although Florida had very strict laws regarding restraints. The protocol for approving restraints for Paige was never initiated. The staff did so without the required guidance and supervision of a nurse and/or doctor. On her final night, she was so ill that she vomited 25-30 times. Medical staff had been contacted multiple times. Yet, no clinician came to check on Paige. And the staffers, in their infinite knowledge, thought Paige might actually be faking her condition - so they took it upon themselves to restrain her to test their theory. Who killed Paige? The whole damn lot of them. 

Tomorrow, Paige's family will mourn their lost child for the fifth year. We did not reach out to the Lunsfords out of respect for their privacy. 

Paige's family members are welcome to contact Echo. 



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ONE YEAR LATER

7/4/2019

One year ago, I put Echo Awareness into hibernation. I walked away. I needed a breather. Audrey Quinn's podcast on Bellwether and the developmental mental system had aired with accolades. I was tired. I was traumatized. I was fighting my own battle at home to regain my child with classic autism who had spiraled into a prolonged manic episode. She'd missed almost half a school year because she was unsafe to herself and others. She has a mean a left hook and phenomenal aim. We were desperate and searching for answers for her. We contemplated in-patient treatment, but there were no facilities in Delaware that had an autism unit. Our daughter would be placed with children who cut, who had eating disorders, who were rehabbing from drugs. All things a child with autism would learn without even trying to due to the nature of the condition. She'd be part of group therapy even though she was non-conversational with limited verbal and had slowed verbal processing. Essentially, she falls behind in conversations and when she does share she's usually several minutes behind and her vocabulary is limited. The one facility that evaluated her, the one with worst reputation but one of the only two in-state that treated children with mental and behavioral health needs, denied her admission. She needed more than they could provided. I was grateful. I didn't want to leave my beautiful daughter in place where there was no autism translator. While we were there a patient set a fire in the bathroom and the police came and put the facility on lock-down. We had to be escorted to our car by police.

With a new psychiatrist on-board, (we got booted mid-episode by the premier children's hospital in Delaware and Florida because her bipolar diagnosis came from an emergency room Psychiatrist in a Maryland hospital.) They lied to us about why they couldn't continue to provide her with behavioral health services. It wasn't that we missed appointments, we were dutiful. We weren't difficult parents. We followed instructions to a T. We were told that the hospital was restructuring its behavior health department to imbed pyschs on the units and they would have little time for out-patient visits. In April, we made the journey to the Mayo Clinic in Rochester Minnesota for a second opinion given she had several cases of altered mental status and seizure like behavior that resulted in ambulance transport from school to the same children's hospital that had dumped us. In May as I read the reports from our Mayo visit, I found the real reason. The hospital was upset that the bi-polar dx came from an ER doctor not their own - one in a small little facility that sat in the county seat of Cecil County, MD, 5 minutes from house, and where the last ICT escort took our family b/c we could not de-escalate our beautiful daughter from her dangerous episode.  The irony? Our children's hospital has contracted to operate the Pediatric unit at the hospital where we finally found the bipolar dx and where the doctor put his foot down and said no more speed. That doctor saved our lives. After a year, the contract was severed, and that smaller independent non-profit hospital is now merging with the largest healthcare system in Delaware. Guess that contract didn't work out. The  Mayo papers were "enlightening." In a time when there is a shortage of mental and behavioral health providers, where waits can be six months or more, hospitals are playing kick the can with our special children. Second opinions not welcome.

And from that moment, I knew I needed a break. That break has come to an end. There are some old Mazik oddities to tie ribbons around and the status of Bellwether in New Jersey desperately needs review because sometimes it's easier to watch children and adults die than it is to do YOUR JOB!


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New Content Coming!

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The Final Decade: Jon Henley

First Victim, Jon HenleyIn 1997, the same year that Au Clair changed its name to Advoserv, the family of Carlton Palms resident Jon Henley received devastating news.

Tuesday, April 8 1997, The Orlando Sentinel published the obituary of St. Thomas resident, the minor, Jon Henley, age 14.  At right is the official published accounting of Jon Henley's death. It is his obituary.

However, in 2015 Heather Vogell and ProPublica published a much more thorough review of Jon Henley's final hours:

First Victim, Jon Henley Tue, Apr 8, 1997 – Page 2 · The Orlando Sentinel (Orlando, Florida) · Newspapers.com
On April 2, Mazik telephoned relatives of a 14-year-old student to tell them the boy had died of an apparent seizure at Carlton Palms. A caller to the state’s abuse hotline a few months later reported that the boy, Jon Henley, hadn’t received immediate medical care for the seizure, and that staff had neglected him. - https://www.propublica.org/article/advoserv-profit-and-abuse-at-homes-for-the-profoundly-disabled
This is a summary of Vogell's reporting of this incident:

While preparing her story, Vogell reached out to Laurice Simmonds-Wilson. Prince Jon Jon, as his family affectionately called him, had been sent to Carlton Palms because his school district in the Virgin Islands was unable to provide the appropriate setting for him. Prince Jon Jon had autism and seizures.  On April 2, 1997, Ken Mazik called his family to inform them he had died as the result of an "apparent seizure." Carlton Palms paid for his casket and the cost of returning his body to the Virgin Islands.

In 2015, through Vogell, Simmonds-Wilson learned for the first time that there had been an investigation in Prince Jon Jon's death. A few months after Jon Jon's death, the state abuse hotline received a complaint - Jon Henley had not received immediate medical care for his seizures and had been a victim of neglect. The investigation found:
  • His roommate reported that Jon Jon was shaking in his bed early in the morning. Staff failed to help him.
  • Jon Jon was laying facedown in his bed. One staffer admitted telling the boy to be quiet because she assumed he was masterbating.
  • Workers were supposed to check on Jon Jon every fifteen minutes. However, he was found at 7:30 am, dead, still lying facedown in his bed.
  • Jon Jon's autopsy revealed that his blood titers for his anti-seizure medication were far below therapeutic levels. 
Yet, Vogell would discover that, "ultimately, despite signs of potential lapses in care, the sheriff's office did not file criminal charges and state investigators closed their inquiry with no finding of mistreatment. The facility faced no repercussions."

Advoserv offered this statement: "Carlton Palms cooperated with the investigations, which found no wrongdoing, and that '[w]hen incidents like this occur, we responsibly address them.'" 

"When incidents like these..." How many had there been? How many were to come?

Simmonds-Wilson would opine differently. Her family had never been notified that an autopsy had been performed on her beloved nephew. According to Vogell, the family felt they had had been deceived. 

"Jon Jon deserved justice. Period."

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Carlton Palms, Sensativity Message

Countdown to the end. It wasn't Carlton Palms' finest hours. The documented and confirmed episodes of abuse are consistent with the creation of a beast so large it cannot be contained. One could opine that facility was akin to doctor mills, except these patients didn't leave but for extreme circumstances. And, to be fair, there were families who deeply believed their loved one was receiving the best care possible. It is not our intention to deprive those families of their beliefs or their support for Bellwether. There will  always be two sides to this story. At least. What Echo has attempted to do is capture what is fact. It's been an effort in restraint. There has been no room for leads and rumors that haven't been substantiated through mainstream channels. Often, there has been difficulty getting agencies in Maryland and Florida to acknowledge Requests for Information and Freedom of Information Act requests. The failure of the departments in each state have stymied our research. However, this blog has consistently relied on accounts previously printed in superior publications, written by trained journalists, fact checked with diligence, and ultimately attributed to these writers and publishers. We owe these reporters and publishers a debt of gratitude.

This is our very special episode of Dr. Phil. Our message above is an effort to warn readers that the posts that follows in the next several posts is sensitive. It is heartbreaking. Gut-wrenching. Devastating. It is the most accurate truth recorded publicly to date.

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AfterEffect Drops in Seven Days, Have you been listening?

https://www.wnycstudios.org/shows/aftereffect

Aftereffect, hosted by Audrey Quinn, has dropped.

ARE YOU LISTENING?

A New Podcast Series Examining How America Fails People with Developmental Disabilities through the Experiences of an Autistic Man Involved in a Police Shooting

What we've learned so far... 

As Charles Kinsey lay bleeding in the street, we hear his shooter (a police officer) say it was a bad shot, the sniper was aiming for the other man.  The other man? He meant the autistic Hispanic man playing with his toy truck as he sat on the street, seemingly unaware, locked out by his disability? Was he a threat? This is where Audrey Quinn's story begins. 

It was a steamy summer of black lives verses blue lives. Amidst national outrage on both sides of the debate, completely unaware of the color war, Arnaldo Rios Soto left his North Miami group home. He wandered down the street and sat in the road with his toy truck. His caregiver, a black man named Charles Kinsey, went to retrieve him. A motorist mistook Arnaldo's toy for gun and called 911. Police arrived and ordered Kinsey to lay down with his hand up. He complied while cell phone video shows him both pleading with Arnaldo to do the same and yelling to the officers that he is Arnaldo's caregiver. Kinsey is shot in the leg. The sniper calls it bad shot. Audio of that day reveals that the shooter claimed to have aiming for the other man.

Following the shooting, Arnoldo was subdued, cuffed with his hands behind his back, and put in the back seat of a police cruiser for several hours while police worked the scene. No one noticed that with his hands restrained Arnoldo could not perform any of his calming measures - flapping his hands, playing with a toy. Instead, he screamed...for hours, after questioning he was returned to his group home. 

The next day, Arnoldo, having had time to process what happened the previous day, eloped again. He returned to the scene where Kinsey's blood still marked the moment police violence had entered their lives. It was clear that Arnoldo was far more traumatized than anyone had previously assumed, assumptions made because Arnaldo was not conversational. 

Unable to contain his grief, Arnaldo acted out. His group home providers sent him for admission to a psychiatric program where he floundered in a system that lacked a proper placement for him. Arnaldo was kept in the psychiatric unit for more than 30 days as the State of Florida searched for a home for him, again. It seems that Arnaldo had been stuck in a revolving cycle of psych placements and group homes. With Kinsey, Arnaldo's family believed he was making progress.  However, Kinsey - who did survive his injury - would never return to the caregiving field of work.  

Eve
ntually, representatives from Carlton Palms came calling. Arnaldo had a new home, a facility with a history of abuse and neglect. It's Halloween when Quinn first meets Arnaldo. He's dressed as a police officer as are most of housemates. Think about it. Arnaldo had been at the center of a police shooting. He's seen his caregiver injured. He's been cuffed, left in a police car, questioned in a police station, and drawn back to the bloody scene. Did police costumes constitute Aversion therapy? Nah, Carlton Palms just got a good deal on police costumes.

 In episode three, Quinn begins to delve into Arnaldo's past. She learns how his mother fought for a diagnosis and access to education for her son. Quinn discovers that Arnaldo has ahistory of being turfed from one setting to another. She's told that the sweet man before her has a past spotted with violent episodes. Quinn's learning that autism is not just a spectrum but that it has two faces. She's also wading into the adult developmental disability service/support system -underfunded, a patchwork cobbled together, an industry consumed by for-profits seeking the highest Medicaid reimbursements they can attain. Here, restraint isn't an option, it's requisite, as countless substantiated complaints about Carlton Palms confirmed. 

Of particular takeaway for parents of those who are developmentally disabled, Quinn interviews autistic people. Yes, Echo is not using people first language; Quinn's sources do not see themselves as a person with extra baggage; rather, they see their autism as an inherit part of themselves which they value. The dichotomy is startling when the conversation turns to self-direction, a requirement of facilities that receive funding under state Medicaid Waivers. These intuit autistic adults turn self-direction on its head and is cause for even the best parents to pause and consider the amount of authority they expect their special children to exercise as adults. Lack of communication skills does not negate the individual mandate. 

What happens next? What was particularly cruel about the Halloween costume? What is the Baker Act? 


Episode Four drops tomorrow!


Live in Florida or Delaware? Then this podcast should be of special interest to you!
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