Safety is not rocket science especially for a well-oiled for-profit, especially ones generating millions in Medicaid funding. It's not that complicated. Protect your resident from others, from the environment, and from him or herself.
Yet, the Independent Monitor Report found Environmental Safety concerns in Bellwether facilities:
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.
"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." (IMR)
BW Training Video (Sarcasm):
BW Training Video (Sarcasm):
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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
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.
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.So what does all the gobblygook mean?
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
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.
"If it wasn't written down, it didn't happen!
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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):
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.
And this was only Page 4 of 15.
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