IF IT WASN'T WRITTEN DOWN, IT DIDN'T HAPPEN!

By Elizabeth Scheinberg

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.

"If it wasn't written down, it didn't happen!

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