The Echo

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.

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. 

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. 

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

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