Leaders say response to Beatrice center problems is dramatic
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By NANCY HICKS / Lincoln Journal Star
It’s like the old-fashioned broken record where a phrase is repeated over and over and over again.
Federal inspectors report serious problems with client care at the Beatrice State Developmental Center, home to more than 300 people with developmental disabilities and cite the institution for what are called “immediate jeopardy” issues, as well as broader systemic problems.
State Health and Human Services leaders promise to do better and make changes.
Federal inspectors from the Centers for Medicare and Medicaid Services described three instances that created an "immediate jeopardy" during the recent inspection of the Beatrice State Developmental Center.
Leaders at the center have taken corrective action on all three immediate jeopardy issues, satisfying inspector concerns. But the center also failed several broader areas and is facing loss of $28.6 million in federal funding.
Recent immediate jeopardy reports:
* Staff members were not sure of the approved way to evacuate clients in wheelchairs from the second and third floors of a building on the campus after a fire alarm sounded. The alarm was false.
Corrective action: BSDC developed more specific evacuation plans and provided more training on how to evacuate people in wheelchairs.
* Staff were slow to stop a client who routinely abused herself by slapping herself or banging her arm, hands or head on a table. The inspector observed the interaction between staff and client over several days. Staff members did not report all of these incidents, did not know they should physically intervene and did not try to determine better ways to stop the self injuries.
Corrective action: BSDC developed a plan for one-on-one supervision of the client, with additional training for staff and a monitoring system.
* Surveyors reported on several clients with injuries with no report on how the injuries occurred. These included a client who could not walk or talk and had fractures of both legs, and a client who said he scratched himself but reported that someone hit him, giving him a bruise. Staff said that client routinely made false allegations and could not always be taken seriously.
Corrective action: BSDC reissued abuse and neglect policy to staff and provided video in-service for staff, among other corrective actions.
Groups representing the interest of people with developmental disabilities recommend that the governor establish a “blue ribbon” commission and call for change, primarily moving people out of the state-run institution into community programs.
The most recent visit of federal Centers for Medicare and Medicaid Services inspectors in late February and early March repeats the same themes, except that now, the state faces the loss of $28.6 million in federal funding.
But state agency leaders say the current response, including the decision to move 100 people from Beatrice into community programs by the first of the year — and at least half of those by July 1 — and a plan to close the on-campus hospital this spring is a dramatic change.
This is a “180-degree turn” in what we are doing at Beatrice, said John Wyvill, the new director for the Division of Developmental Disabilities for state Health and Human Services.
The most recent federal inspection shows that Beatrice is failing in the same areas in which it has failed before, said Deb Weston, director of The ARC of Nebraska.
Two of the three problems cited as “immediate jeopardy” issues during the recent visit are repeats of problems, according to Bruce Mason, litigation director for Nebraska Advocacy Services, whose agency has studied the federal reports and conducted its own investigation.
Problems with staff who do not stop clients from hurting themselves or try to find better ways of getting clients to stop the behavior has been documented by previous investigations, said Mason. The problem “clearly exists and has not been eradicated or even minimized,” he said.
There is also a history of minimizing the seriousness of self-injurious behaviors, he said.
An Advocacy Services investigation also pointed to cases in which clients were injured but there was no indication how the injuries occurred, he said.
“This is one of the most troubling aspects of the CMS findings that coincide with our findings,” Mason said.
“There does not seem to be an ability to eliminate, to report or even to take appropriate intervention activities,” he said.
Federal inspectors have found immediate jeopardy issues during at least four visits since September 2006.
This week, two groups representing people with developmental disabilities — The ARC of Nebraska and ADAPT NE — again urged Gov. Dave Heineman to create a commission that would investigate problems at Beatrice and look at the state’s system of caring for people with developmental disabilities.
These two groups and Nebraska Advocacy Services want a commission much like one established by former Gov. Norbert Tiemann that led to creation of the current community-based system of care.
But the administration has not given any indication there will be such a commission, leaders of those groups say.
“We haven’t heard anything back on the gubernatorial commission, except to say they received our information,” said Mary Agnes, spokeswoman for a grassroots advocacy group called ADAPT NE.
“What is lacking is an overall plan,” said Mason. What’s occurring now is on an “ad hoc basis.”
“To deal with issues that impact Nebraska’s most vulnerable requires the best minds in the state to come together,” he said.
“There appears to be a lack of political will in the governor’s office to give this a concerted effort,” Mason said.
Heineman said he understands the advocacy groups’ concerns and is considering them, but didn’t say whether he would establish a blue ribbon commission. He did say that Health and Human Services has brought in an expert group, Liberty, to help solve issues.
Reach Nancy Hicks at 473-7250 or nhicks@journalstar.com.
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As we all know it is not really possible to put the genie back in the bottle. For what ever reason the individuals in the BSDC can not live in the community it is not likely to get any better with out a new way of looking at the situation.
We have to ask what is more important then the quality of life? What good does it do to have a person who hurts themselves or others for the sake of saying that that person is not on medications that would help them calm down or control them selves. There is a balance here. I know from being the parent of a developmentally disabled (DD) child that sometimes you have to trade one thing for the other. There is a huge push in the DD community to live "restraint free" This lack of restraints often leads to the person’s escalation into a fit of rage or into self inquiries behavior (SIB). I feel, as do many people that I would rather have my child slightly sedated rather then watch that child hurt themselves or others during a tantrum, yet there is a continual push to lessen the medication. Then also to lessen the ways that staff may deal with the behavior until they get to a critical point and it becomes “tackle” situation where the individual is forced into a physical restraint.
There is also there is a trend toward paying the staff in these institutions and group homes less then those people who are working in fast food. The company who does my child’s vocational work shop gets paid thousands of dollars each month just for my child yet the staff makes 6 something an hour. What is the quality of person you are going to attract at that wage? What is the motivation of that person to stay and become a fixture in the lives of these individuals if they can not live on their wage? The whole system needs to be looked at, changed and instead of pointing fingers at each other a proactive stance needs to be taken. One that allows for the care of these people as individuals and not as a herd of animals that can be cared for under a blanket of rules that is implemented by overworked, underpaid, and stressed out people.
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1. Why was a nationwide search conducted for a CEO when we settled for someone without administrative or even basic supervisory experience? Keeping in mind only four people were interviewed out of a possible 80. Does the State truly want capable people at the helm? Will the lack of leadership doom the facility?
2. Why has the facility gotten worse since Nebraska's payments to Liberty of over 1.5 million dollars to correct the deficiencies? Why would Liberty recommend a return to a previously failed organization structure, one that was the root of the initial problems? Didn't CMS have trouble with that organizational structure?
3. Is the fix in to hire Liberty long-term? Didn't the administration reassure Liberty that they would try to help keep them on despite the RFP? Why do many of the Liberty people come from closed institutions? Don't many of the Liberty staff have ties to CMS? Does something smell fishy about the audits?
4. Why does the Governor keep Chris Peterson on as HHS CEO despite the repeated problems at our State's facilities and within our social service structure?
Your paper has not done enough to truly investigate the situation. Maybe others can assist your paper with questions to pursue as well.
The single bright spot has been that the legislature has finally aroused itself from its slumber. Perhaps it will take up the cause and search for answers to the facility's woes? I tend to doubt it though. "
I would recommend that tax payers go visit the center to see the residents and the intense nature of their disabilities. Moving them into the community will not be the answers due to their medical and behavioral needs and most likely cause more injuries with both staff and former reidents. "
If you really want to know what's going on here - come visit. We're proud of what we do - we do the best we can under extremely difficult circumstances that no other agencies are required to meet. CMS is another out of control agency - like the IRS used to be before they got "friendlier"!!!! Come see us - and decide for yourself whether those who live here are safe and well cared for, ask the parents and family members. Do NOT rely solely on agencies who make no secret that they want to see our doors closed forever! "
There seems to be this unrealistic expectation that if BSDC is not going to be able to thrive and funding pulled from BSDC, then "hey, let's just transition to community based programs and group homes".
Why is this unrealistic? As Dee stated in her post, not every individual at BSDC meets criteria for community placement, because of medical, behavioral issues, etc. Having worked in a group home that served individuals with high behavioral needs, I can also state that so many in the community that are clucking their tongues over issues at BSDC are some of the same people who boycott group homes in their neighborhoods, harass the residents and staff of the group homes, and act in ways that are downright hateful to those living in group homes.
Add community stigmatization of the individuals living in group homes (they're not crazed child molesters, you know!), lack of staffing (yes it's a problem with other providers, not just BSDC), and the fact that in community programs, the staff are often paid next to nothing to work in what can sometimes be a dangerous, stressful environment and tell me how this solves the problem of substandard care at BSDC and its possible loss of funding?
The individuals at BSDC and their families deserve not just answers, but action from our sorry acting government. If this were happening to any other minority group, we would call our lawmakers on it IMMEDIATELY. "
www.usdoj.gov/crt/split/documents/beatrice_sdc_findingsletter_03-07-08.pdf "