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4/22/2015 Survey Tag 0001 Detail for:
PUEBLO REGIONAL CENTER
Friday, November 15, 2019 12:49 AM

Survey Date: 4/22/2015

Regulation Number:0001

Regulation Title: Survey Details

Regulation Description:

Surveyor Findings:


8.608.8 ABUSE, MISTREATMENT, NEGLECT, AND EXPLOITATION

A. Pursuant to section 25.5-10-221, C.R.S., all community centered boards, service agencies and regional centers shall prohibit abuse, mistreatment, neglect, or exploitation of any person receiving services.
B. Community centered boards, program approved service agencies and regional centers shall have written policies and procedures for handling cases of alleged or suspected abuse, mistreatment, neglect, or exploitation of any person receiving services. These policies and procedures must be consistent with state law and:
7. Require reporting of allegations within 24 hours to the parent of a minor, guardian, authorized representative, and community centered board or regional center;
8. Ensure prompt action to protect the safety of the person receiving services. Such action may include any action that would protect the person(s) receiving services if determined necessary and appropriate by the service agency or community centered board pending the outcome of the investigation. Actions may include, but are not limited to, removing the person from his/her residential and/or day services setting and removing or replacing staff;

8.604.1 RIGHTS OF PERSONS RECEIVING SERVICES
A person receiving services has the same legal rights and responsibilities guaranteed to all other individuals under the federal and state constitutions and federal and state laws including, but not limited to, those contained in section 25.5-10, C.R.S., unless such rights are modified pursuant to state or federal law.

These standards are not met as evidence by:

The Colorado Department of Human Services (CDHS) is legally responsible for the oversight and management of all state regional centers. This purview specifically includes the Pueblo Regional Center. In the case of PRC, certification encompasses ten individual Group Homes in addition to the Day Habilitation program. Whereas, within the context of licensing, each Group Home is separately licensed. Given the relationship between CDHS and PRC, Pueblo Regional Center staff are State of Colorado employees.

According to interview (cited below), organizationally the Pueblo Regional Center is overseen by CDHS ' Office of Community Access and Independence, more specifically the Division of Regional Center Operations. Consequently, the following citation addresses the actions taken by CDHS as the oversight authority of the Pueblo Regional Center.

The Pueblo Regional Center (PRC) is a service agency licensed and certified to provide Group Residential Services and Supports (e.g., Group Homes). Certification within the Home and Community Based Services- Persons with Developmental Disabilities (HCBS-DD) Medicaid waiver includes the provision of Day Habilitation Services and Supports in addition to residential services. The Colorado Department of Public Health and Environment (CDPHE) is responsible for conducting HCBS-DD waiver complaint investigations on behalf of Health Care Policy and Financing as part of an interagency agreement. Moreover, CDPHE is responsible for conducting surveys and complaint investigations under its licensing authority.

In accordance with the Home and Community Based - Persons with Developmental Disabilities (HCBS-DD) Medicaid waiver, Group Residential Services and Supports are designed to assist persons to live as independently as possible and support integration into typical activities within the community. Services may include self-advocacy training, assistance in expressing personal preferences, and independent living training, (i.e., personal care, household services, and communication skills). It should be noted that Group Homes are community-integrated homes and are designed to be typical to a normal household setting. Whereas in an institutional setting (i.e., nursing home, hospital, etc.), all medical needs are met by the institution; persons living in Group Homes have their own private physicians and medical supports within their community. Persons receiving group home services must meet eligibility criteria including a diagnosis of intellectual and development disabilities at a level that would otherwise require institutionalization in an intermediate care facility (Pursuant to C.R.S. § 25.5-10-221 1(a)).

Summary of Findings:

Based on record review, staff interviews, guardian interviews and interviews of persons served, the PRC, through the actions of Department of Human Services (DHS) governing body officials, failed to adhere to established policies and procedures with regard to mistreatment, abuse, neglect and exploitation (MANE), in accordance with 8.608.8. In doing so, the DHS failed to protect and ensure the same rights guaranteed to all other individuals under federal and state law, in accordance with 8.604.1. Particularly, it failed to ensure individuals ' rights to personal privacy, dignity and respect. The DHS also failed to allow the individuals or their guardians the opportunity to give informed consent to inspections of their bodies.

These body inspections, for which the DHS could not provide a specific explanatory catalyst, were conducted on 03/25/15 and 03/26/15. According to complainants, 62 people were "strip searched " in 10 different community group homes and one day habilitation site for unknown reasons.

An investigation by the Colorado Department of Public Health and Environment revealed body inspections were completed by DHS governmental employees without the persons served [by PRC] being adequately informed about the purpose of the inspections, what it would entail, and without obtaining informed consent from either the individuals or their appointed guardians. It was found that the searches were conducted in such a way as to cause significant distress. Further, forty of the persons served were previously adjudicated incompetent to make decisions regarding their own health, care and welfare and had legal guardians appointed by the court. Yet, no guardians were contacted to give consent to the inspections, nor were any guardians informed within 24 hours of the suspected abuse.

Persons who did not want to participate in the body inspection felt they had no choice. Non-verbal persons' behaviors indicated they, too, did not want to participate in the body inspections; yet, the inspections were conducted in spite of the persons' protests. Ultimately, the body inspections resulted in the persons being confused, scared, and some were distraught to the point it negatively affected their behavior.

Findings:

1. A complaint was received on 03/30/15 alleging Wheat Ridge Regional Center staff, who are employees of DHS but were not a part of the Pueblo Regional Center (PRC), entered the Pueblo Regional Center in mass. The complainant alleged the Wheat Ridge staff "strip searched" all the persons living in 10 different community group homes and one day habilitation site for unknown reasons.


The sites entered included:
198 E Galetea
262 S Bayfield
268 Harmony Drive
272 Harmony Drive
330 E Hahn's Peak
416 E Maher Drive
496 S Latimer
614 S Clarion
887 S Bellflower
895 S Bellflower
Day Habilitation site located at PRC administrative offices

An investigation was initiated on 03/31/15. During and after the completion of the onsite portion of the investigation, nine additional complaints were received from guardians of affected persons.

2. Pueblo Regional Center Policies:

Agency Policy 1.4 Rights of Persons Receiving Services - states: "The purpose of this policy is to outline the steps necessary to ensure the protection and knowledge of civil and human rights of all people living at the Pueblo Regional Center." The policy defines Personal Representative - a person who is given the authority in writing by the person receiving services to act on their behalf. It should be understood that when the "person" is referred to in this policy, that the person, person's guardian or personal representative is implied." The policy also gives the agency the responsibility to protect the rights of people living at PRC (C.1.), establishes a third party human rights committee to review all allegations of abuse and mistreatment (C.2.), and holds the agency responsible to ensure all necessary procedures are enforced to protect the people receiving services (C.3.). The policy goes on to direct that rights may be suspended only to protect the individual from endangering self, others, or property and such rights may only be suspended by the interdisciplinary team and in a manner that will promote the least restriction on the patient's rights (E.1.).

Agency Policy 1.4 Rights of Persons Receiving Services also expressly states that the Agency Director, Director of Social Services, or designee may take emergency action to suspend the rights of a person. The process is outlined that the case manager must be notified within 24 hours, the suspended right will be explained to the person, parent, guardian or authorized representative within 24 hours.

Agency Policy 1.5.C1 Human Rights Committee defines informed consent: "means an informed assent, which is expressed in writing and is freely given. Consent includes fair explanation of the procedures to follow: discomfort, risks and benefits, appropriate alternatives, opportunity to answer questions, ability to withdraw consent ..."

Agency Policy 1.4.A2 Abuse, Mistreatment, Neglect, and Exploitation outlines a series of steps to be taken by the agency. The steps include notifying the primary nurse or nurse on duty in the event of an injury or allegation of physical abuse to assess the individual, receive witness accounts, treats the victim with dignity and respect (A.-C.). The Emergency on Call staff or delegatee is to immediately notify (D.2.) the individual s legal guardian or authorized representative (the immediate notification is repeated in 1.5.I1A Critical Incidents and Reportable Occurrences).

3. Interviews with staff showed that DHS failed to protect rights of individuals, obtain informed consent, and failed to follow specified investigation procedures which caused significant distress to several individuals.

Interviews were conducted with staff working in the day habilitation site where the body inspections initially began. The majority of persons that received services in the day habilitation site were persons with intellectual and developmental disabilities. Most persons were in need of full support with all activities of daily living, required total assistance with turning and repositioning, and had few to no verbal skills, but could generally make their basic needs known to staff through facial expressions, gestures and sounds within the day habilitation site. Interviews and observations revealed that these individuals could not provide consent due to their disabilities. Moreover, there was no evidence to demonstrate efforts were made by the DHS to advise guardians of allegations of abuse (8.608.8 B7) or to obtain consent from guardians for the body inspections (8.604.1).

a. Staff #8 was interviewed on 04/02/15 at 10:05 a.m. She stated she was working in the day habilitation site at the time of the body inspection on 03/25/15. She stated there were at least six team members and they worked in teams of two.

i. Staff #8 was with the body inspection team when they inspected person #13. She stated the body inspection team started at person #13's head and examined down her body. They took her blouse off; she was not wearing a bra, and pulled her pants down. Staff #8 noticed the person was wet so she proceeded to change her incontinent product. The team requested they leave the incontinent product off so they could examine the person's perianal area. When the body inspection team completed the examination, the team moved to another person and left staff #8 to redress person #13.

ii. Staff #8 stated the next person the team conducted a body inspection on was person #20. Staff #8 stated person #20, "was not receptive to that at all. He was afraid, very afraid, he was shaking and he was saying No." Staff #8 stated the person was fearful, striking out and pushing them away. Even with the gestures of refusal, the team continued the body inspection. Staff #8 stated the body inspection team took his shirt off and examined his upper extremities and "he was batting them away." Staff #8 said she assisted person #20 to stand and the body inspection team took his pants down and checked his legs. Staff #8 said that was when the person was laid down and the inspection team removed his incontinent product. Staff #8 stated person #20 "was batting them away the whole time. They took his [incontinent product] off and that was very frightening for him because the male person that was examining him basically was moving his penis around, not basically, did move his penis around and his testicles and he did not like that. He was fearful; you could tell he was fearful." Staff # 8 stated person #20, "has been agitated since then. He has wanted to strike out. He is not a happy camper."

iii. Staff #8 stated the next person the team wanted to inspect was person #21. Person #21 was in a rocker recliner at the time of the examination by the team inspection. Staff #8 stated there were "way too many people in there; it was very disruptive to the whole group." Staff #8 stated person #21 was laying on her back in the recliner and the inspection team lifted her blouse up, she did not have on a bra. They checked her chest and back. The team pulled down the person's pants to below the knees and looked at her legs.

iv. Staff #8 stated the team did not ask permission prior to conducting the body inspection. Staff #8 said, "I've been employed here for almost 28 years and when they came in, they came in like gang-busters. I was literally told, I was toileting someone and we were coming out of the bathroom, and I was told by kind of an indirect supervisor, they are going to come in and they are going to do full body inspections. I said, oh, okay and literally walked into the room, they were all in there, and they all came in like a big herd of cattle and just started going at it. I mean it was, it was very disruptive. I can imagine what the guys felt like, 'cause it was upsetting to me and I wasn't the one being examined."

b. An interview was conducted with staff #11 on 04/01/15 at approximately 11:00 a.m. Staff #11 stated she worked with person #18 daily for the past 12 years, and as part of her job, provided him with showering, changing incontinence products and repositioning.

i. She stated she was working with the person at the time of the body inspection. She knew his gestures and behaviors well. She stated she assisted the Registered Nurse (RN) from the Wheat Ridge Regional Center with the body inspection of person #18. Staff #11 explained the RN told person #18 what he was going to do, while another member of the inspection team explained to staff #11 the team wanted to ensure the persons "were safe." Staff #11 stated the body inspection for person #18 consisted of the RN examining person #18's eyes, ears, nose, chest, legs, genitalia and buttocks. Staff #11 stated during the body inspection, person #18 was grimacing and moaning and that was how he showed he was uncomfortable. Staff #11 stated person #18 was normally smiling and laughing. She stated person #18 was so tense and contracted the RN could barely get his hand open to check his palm.

ii. Staff #11 stated other persons were also affected by the body inspections. Staff #11 stated person #17 was very agitated after receiving the body inspection and person #14 had been very cranky. Staff #11 stated she was uncomfortable with the body inspection and she "felt it was intrusive ... invasive." She stated, "these people [persons] don't know them [inspection team] but they just came in and started looking at private body parts."

c. An interview was conducted with staff #9 on 04/02/15 at 10:25 a.m. She stated she had worked at the service agency for three and one-half years. She stated she provided full care to the persons as well as administering medications.

i. Staff #9 stated she was working with the persons living at her assigned home when they were in the day habilitation site on 03/25/15. Staff #9 stated she was with person #14 when he was examined by the body inspection team. Staff #9 explained she had worked with person #14 for almost two years and although he was non-verbal, he was expressive with facial expressions and he will make sounds. Staff #9 stated she knew he was uncomfortable during the body inspection because he was pushing their hands away. He was "pushing their hands away because he was unfamiliar with them. He even does it with us his home staff if he is not in the mood to be bathed or those kinds of things." Staff #9 stated, "They were less invasive on his body inspection, they checked his back, they checked his leg, checked his arms, but they did want to see his behind and check it for marks. They informed me at the time they found nothing to be concerned of." Staff #9 said she felt the process was "invasive." She stated, "It had to be horribly uncomfortable for them especially since they don't know what is going on."

ii. Staff #9 said, "I will say that I know I did very much notice that a couple of the persons in our house that are more verbal were very uncomfortable and did continue to have some behaviors that would have indicated that they were agitated over the next couple days." She stated the persons were person #17 and person #15.

iii. Staff #9 said, "That day, it literally felt like they all swooped in and swarmed the group. There was at least six of them, might have been eight." Staff #9 stated, "It was very invasive to the clients. They are very tuned in to what's going on around them as far as they can feel tension, they can feel anxiety from other people, they can feel stress, and I think the way it was handled was very poor. It amped up the environment in the room, not in a good way." She stated staff could not attend to persons' needs because they had all the privacy screens in use. It was not fair to them.

4. Interviews of persons served were conducted on 03/31/15 and 04/01/15. Interviews were conducted with at least two sample persons in each home or with the staff who were present at the time of the body inspections. The interviews substantiated the complaint allegation that individuals unknown to the persons [strangers] inspected their entire bodies. Interviews also showed there was inadequate information given in order for persons to understand the situation or to give informed consent (8.604.1). Moreover, guardians were not contacted regarding allegations of abuse (8.608.8 B7), nor prior to the completion of the body inspections (8.604.1).

a. Person #6, #7, #8, #9 and #10 were interviewed on 03/31/15 beginning at approximately 4:10 p.m. All persons confirmed outside people they did not know (Wheat Ridge Regional Center staff) conducted inspections of their bodies without their knowing why or giving an opportunity for informed consent.

i. Person #6 said the outside people (Wheat Ridge team) would not let PRC staff be present at the time when she was examined. Person #6 stated she would have liked to have known why the team was doing the body inspections, but "they didn't tell us." Person #6 thought the body inspections were invasive and she stated the inspections were "not normal." Persons #6 said she was uncomfortable. Additionally, review of an incident report (IR) dated 03/27/15, showed person #6 told staff, "[Agency] people came out the other day, did body inspections on us all and the funny thing I don't know why." Staff stated, "I ' m sure they did tell you." Client stated, "No I would have remembered." The IR confirmed the information given by person #6 during an interview on 03/31/15.

ii. Person #10 stated she did not like the body inspections. Person #10 said she was uncomfortable and the inspection team "did not know our past." Persons #7 and #9 also stated they did not like the body inspections.

iii. Persons #7, #8, #9 and #10 confirmed staff were not allowed to be with them when they were examined. None of the persons stated they were asked permission for the Wheat Ridge team to view their bodies prior to or during the body inspections. Two of these individuals had guardians and two others were their own guardians.

b. Person #1 was interviewed on 04/01/15 beginning at 4:30 p.m. Person #1 did not have a guardian and made her own decisions. Person #1 stated she was not given a choice whether to allow the body inspection to occur. She stated she did not like it but she felt she had to comply. There was no evidence the Wheat Ridge Regional Center team asked person #1's permission prior to conducting the body inspection.

c. Person #19 was unable to speak. An interview was conducted with PRC staff #24 on 04/01/15 at 4:30 p.m. Staff #24 stated he was able to witness the Wheat Ridge Regional Center team conducting the body inspection of person #19. Staff #24 stated person #19 stopped the body inspection when the Wheat Ridge Regional Center team wanted to pull his pants down. Even though person #19 was non-verbal and unable to give consent, the person's guardian was not notified of the body inspection until 04/01/15, six days after the body inspection was conducted.

d. Person #2 was interviewed on 04/01/15 at approximately 4:50 p.m. He stated he complied with the body inspection until they asked him to pull down his pants and he then refused the rest of the inspection.

5. Interviews with guardians evidenced that PRC failed to provide notification within 24 hours.

Interviews were conducted with guardians on 04/01/15 and 04/02/15. The interviews again substantiated the allegation the body inspections were conducted without guardian knowledge or consent and in some cases without regard to prior events of psychological trauma (8.608.8 B7).

a. An interview was conducted on 04/01/15 at 2:45 p.m. with the guardian of persons #7, #9 and #12. She stated she was notified on Friday, 03/27/15 about a lump on person #12's head. However, she was not told about the body inspection that had occurred at the same time. She stated person #12 was followed by hospice and that the hospice registered nurse (RN) had examined person #12, but found no lump.

i. The guardian stated she telephoned and spoke with persons #7 and #9. She stated both persons #7 and #9 told her they tried to refuse, but the Wheat Ridge Regional Center team performed the body inspection anyway. Both persons told their guardian on 03/27/15 that they were told by the body inspection team they "had no choice."

ii. The guardian stated the full body inspections were "gross rights violation." She stated she was "pretty outraged" the persons had to have the body inspections and now "the damage was done." She was not contacted about the body inspections prior to or at the time the inspections were conducted and did not give consent for the inspections.

b. The guardian of person #11 was interviewed on 04/02/15 at 11:25 a.m. He stated he was notified about the full body inspections on 04/01/15. He stated he was "quite upset about the body inspections" and stated they "didn't contact me." The guardian stated he flew into the state "today" (04/02/15) after being told the day prior about the inspections. The guardian stated person #11 was a victim of psychological trauma in the past, and if he, the guardian, had known about the body inspections before they occurred, he would have flown in to be with person #11 during the body inspection. The guardian added "his rights were violated by him not consenting to the body inspection."

c. On 04/03/15, guardian of person #5 stated she received an email from another guardian of a person at the PRC asking if she and her husband knew that the persons of PRC had been "searched" on March 25th. She responded that neither she nor her husband were contacted by Regional Center staff regarding the " search " of PRC persons on or about March 25, 2015. She stated person #5 "was clearly upset" by the event and that she had initially refused the search, but the inspection team was "insistent" and searched her anyway.

d. Parents and guardians for persons #15, #22, #23, and #24 voiced similar concerns about the body inspections and the lack of understanding why the inspections occurred.

6. Interviews with administrative staff showed that PRC failed to prohibit abuse, mistreatment, neglect, or exploitation of persons receiving services and failed to follow established investigation procedures.

Interviews with Pueblo Regional Center administrative staff were conducted on 03/31/15 as to the events surrounding the body inspections conducted on 03/25/15 and 03/26/15. Interviews showed that the Department of Human Services (DHS) entered the service agency without notice (8.608.8 B7) and commenced body inspections of the 62 people served by the service agency (8.604.1). Additionally, they provided the Pueblo staff no information regarding specific allegations and little to no details as to why the activities were occurring.

a. An interview was conducted with PRC Executive Director on 03/31/15 beginning at approximately 2:30 p.m. She stated the Department of Human Services, Director of Office of Community Access and Independence (OCIA) responsible for overseeing the PRC, unexpectedly entered her office on 03/25/15 at approximately 8:30 a.m.

i. According to the PRC Executive Director, the DHS Director of OCIA thought there were "major concerns" and gave an example of a historical allegation that had been addressed long ago [see "paranormal activity" below in 8.a.]. She stated the Director of OCIA had questioned her about incident reports being thrown away. She went on to explain to the Director of OCIA the PRC incident report process and that it takes a different course than one for an intermediate care facility like Wheat Ridge Regional Center. The Director of OCIA also alleged that the Pueblo County Sheriff ' s Department stated staff at the service agency were hiding abuse. The Director of OCIA had insisted that people at the service agency were hiding abuse and told the PRC Executive Director there was an allegation of abuse, but was not specific to what the allegation entailed.

ii. The PRC Executive Director stated another Department of Human Services employee, the Director of Regional Center Operations (DRCO) also entered the building with nine other staff from Wheat Ridge Regional Center (WRRC). She was not introduced to the nine other staff. She stated the Department of Human Services DRCO Director told her the nine staff were going to conduct full body inspections on all persons served by the service agency. The DRCO Director had wanted to use the shower room for the body inspections, but the PRC Executive Director had responded back "I think that is abusive, it is like being molested in a public bathroom. They will be scared enough having total strangers look at their bodies." Some persons were in the Occupational Therapy/Physical Therapy (OT/PT) room where day habilitation was being conducted (the day habilitation was conducted in a separate location away from the persons ' homes). She informed the Director of DRCO there were privacy screens in the OT/PT room. The DRCO Director then decided they would start the body inspections on the persons in the OT/PT room at day habilitation; and, for the persons not in the OT/PT room, the body inspections would be conducted in the persons ' home.

iii. The PRC Executive Director stated the majority of persons had guardians to make decisions and further stated to her knowledge, the guardians were not notified the body inspections were going to be conducted. She added that there had been no systemic notification of guardians; the only guardians that were notified were the guardians of persons with which the body inspection team found concerns.

She related she received a call from a guardian the morning of 3/31/15. The guardian had been out of the country when she received a call that body inspections were conducted on two of the persons she supported (persons #7 and #9). The guardian told the PRC Executive Director she called persons #7 and #9 and asked them if the body inspections occurred and they both said ' yes ' . The guardian added, the person #7 and #9 did not want to have the body inspections "but they were told they had to." The guardian stated they were made to take their clothes off, and she was told they had to pull their pants down, show their bottom, pull their shirt up, and show their breasts.

iv. The PRC Executive Director stated staff had come to her very upset about the full body inspections. She stated staff felt the dignity of the persons had been violated.

v. On 04/01/15 at approximately 10:00 a.m., the PRC Executive Director stated person #10 had come to see her and was very upset about the full body inspections. She stated other individuals were also affected and said persons #6 and #7 became physically aggressive. She added, this was most likely precipitated from the stress of the situation. According to the PRC Executive Director, police and Adult Protective Services (APS) were called and person #6 had to be transported to the hospital for a mental health evaluation and was not returned to the facility until the next day.

b. On 03/31/15 at approximately 3:15 p.m., the PRC psychologist/program services director (PSD) was interviewed. The PSD stated he was not informed full body searches were being conducted until "first thing in the morning" on 03/26/15. He stated he learned from PRC staff on 03/26/15, that body inspections were conducted in the day habilitation site on 03/25/15.

i. The PSD stated he "had some concerns about some of the higher functioning homes in terms of what was going to happen to them [the persons] if they refused because we've got some individuals here with past traumatic issues and so I was very concerned about that."

ii. The PSD stated there were higher functioning men and women who had suffered sexual trauma in the past, some are diagnosed with Post Traumatic Stress Disorder. He stated, "You know the majority of our individuals that have been here long term, many of them had been in a variety of institutional type settings and you know even foster care probably growing up to where there is a high probability they experienced that. So, there is a large majority of our population that would fit that clinical mold." The PSD stated concerns including the fact that some of the persons served would likely not feel comfortable refusing when asked or told to participate in the body inspections.

iii. Furthermore, the PSD explained he worked with several persons in the homes who had past sexual trauma. He explained that for many of those persons, the body inspections could have created potential for harm. He stated, "I think if even a familiar staff had to do it [the body inspection] there is a possibility for retraumatization for some of those individuals. Yes. And in fact, one of the homes that I probably have the greatest concern about would be with individuals with borderline personality disorder in their diagnoses; and many individuals with borderline personality disorder often have had early trauma experiences. And I know many individuals have. That was also a home that I was told by my personal coordinators, who were present at the time the body inspections were going on, that they did not, they were not permitted to assist during the body inspections there. So, I have some concern about that." The PSD added, trauma might not manifest itself immediately, that it could manifest itself even months in the future.

iv. Lastly, the PSD summarized that there is a potential that what occurred [the body inspections] could cause further trauma. He explained, "... it could be harmful. Psychological harm for sure. In fact, another concerning aspect of some of the body inspection sheets that I've seen, and I wasn't present during any of them, but it's clear that some of the individuals had an inspection of genitalia. That doesn't seem warranted in my mind; why you would do that? Usually, if there is an allegation of abuse and neglect in a particular area, you have a qualified medical person, like an RN and familiar staff, looking in those areas. So, the whole process seems quite flawed to me. I am worried about the persons and the impact on them, especially non-verbal ones who are even more vulnerable."

7. Record review affirmed the guardian reports (see above) that guardians were not notified prior to the Department of Human Services (DHS) Division of Regional Center Operations (DRCO) conducting body inspections of the 62 persons in regards to concerns of MANE (8.608.8 B7).

a. PRC Policy 1.4.A2 required in response to an initial allegation of abuse: staff will ensure " immediate notification to the individual ' s legal guardian or authorized representative " (D.2.) and notify the respective case manager (D.3.).

b. PRC records document the Wheat Ridge team (selected by the Department of Human Services administrative staff) conducted full body inspections on all persons in the day habilitation site on 03/25/15, beginning at approximately 9:30 a.m. PRC records also show that each person (within the day habilitation program) had a guardian on 04/01/15. However, the guardians were not notified prior to or immediately after the body inspections. Three of the six guardians of the persons first subjected to the body searches were notified on 04/01/15 or 04/02/15 and messages were left for the guardians of the remaining persons (about a week after the full body inspections were conducted).

c. PRC records illustrated DHS failure to provide immediate notification to guardians. Of the 33 guardians identified providing supports to 40 of the 62 individuals, records showed that by 04/02/15 (8 days after the body inspections were conducted), only 17 guardians had been notified about the full body inspections.

d. On 04/20/15, the Executive Director of the Community Centered Board, which acts as the case management agency for PRC, confirmed in a public meeting he was not initially informed of the body inspections.

8. Interviews with the Wheat Ridge staff further showed that there was a failure to protect rights of individuals, failure to prohibit abuse, mistreatment, neglect, and exploitation, and a failure to follow specified investigative procedures.

Interviews were conducted with staff from Department of Human Services (DHS) - Wheat Ridge Regional Center (WRRC) staff, who performed the full body inspections. None of the members of the body inspection teams reported they had provided full information regarding the scope of what each person was going to be asked to do, nor were they directed to ensure informed consent was received from the persons served (8.604.1) or from persons' guardians prior to or during the body inspections (8.608.8 B7). When asked, WRRC staff could not provide the catalyst that merited the full body inspections of 62 people, at 10 individual group homes and one day habilitation site. The following interviews revealed DHS did not ensure prompt action to protect the safety of persons receiving services, such as removal or replacement of staff, at the time the allegations were received (8.608.8 B8). Instead, without focus of any direct allegation, DHS made no attempt to identify alleged perpetrators prior to their completing the body inspections (8.606.8 B8).

a. Interviews were conducted with seven of the nine team members that conducted full body inspections on persons on 03/25/15 and 03/26/15. The teams are identified as team A, team B and team C.

i. An interview was conducted with staff #25, on Team A, on 03/31/15 at 2:00 p.m. She stated her team consisted of staff #25, staff #26 and staff #27. She stated her team was asked to go to PRC and "lay eyes on all 62 persons." She stated she was told there were concerns of abuse and persons ' safety needed to be ensured. Staff #25 stated when the team(s) arrived at PRC, they were to explain the reason they were there was to ensure persons ' safety. Additionally, they were to notify staff and persons that they were going to conduct full body inspections on all the persons. She stated the teams explained the body inspections to the persons by: asking if the persons felt safe; checking the persons' bodies; and looking at persons' skin. When asked the methodology for ensuring the rights and privacy of persons were respected, staff #25 replied, "we asked if they felt safe."

Staff #25 stated the processes of the body checks were to be explained to non-verbal persons and then look at their faces to determine if they understood and gave consent. She stated if the persons could not give consent, they would not do the inspections.

ii. An interview was conducted with staff #27 on 03/31/15 at approximately 2:40 pm. Staff #27 was on team A. She stated the team was told there were reports of abuse and suspected abuse at the PRC. She stated she understood that allegations had been reported, but were unaddressed. Staff #27 could not identify to whom the alleged abuse or suspected abuse had been reported. She stated she thought the information came from senior leadership. She explained her responsibility as a team member was to observe the environment and interview staff (day habilitation and in the homes). Staff #27 provided no information about obtaining guardian consent of the 13 persons with guardians her team reviewed.

iii. An interview was conducted with staff #26 on 04/01/15 at 9:15 am. Staff #26 was on team A. She stated she was told there were complaints, allegations of abuse, concern for "pervasive abuse," and that the Quality Assurance staff at the service agency was "not trustworthy." Staff #26 stated the team was instructed: to look for any signs of physical abuse; look at head, neck and limbs with staff assistance to lift shirts and pulling down pants, if needed; and to do a thorough body check meaning [looking at] everything. Staff #26 stated team members were to explain the body inspection process to persons by introducing themselves, stating they were concerned about the person's safety, and they were going to do a body check. In regard to informed consent, she stated she assumed the agency had consents to provide general medical treatment and to administer medications. She explained this was her assumption as this is the case at WRRC. When asked if the guardians were contacted, she stated she did not think so.

iv. An interview was conducted with staff #18 on 03/31/15 at 2:40 p.m. Staff #18 was a member of team B. She stated the Director of the Department wanted "eyes on [the service agency]" for all 62 persons to assure the safety of the persons and follow up on potential abuse to vulnerable persons. To ensure the persons' rights to privacy, staff #18 stated the members of the team introduced themselves and said they were going to look at their skin. She stated if persons refused, the team would not conduct the body inspection. When asked if the guardians were contacted, staff # 18 replied, "None of the guardians were made aware that I know of." At the time of the body inspections, there were 17 persons living in the homes in which team B conducted the body inspections. Of the 17 persons inspected by team B, 12 had guardians. There was no evidence the 12 persons ' guardians were notified of, or gave consent for, the full body inspections prior to proceeding or during the body checks.

v. An interview was conducted with staff #19 on 03/31/15 at 3:00 p.m. She was on team B. She stated her understanding of the purpose of the full body inspections was to perform a head to toe physical assessment to determine if mistreatment, abuse, neglect and exploitation (MANE) had occurred. When asked how she would ensure the persons rights and privacy, staff #19 stated she asked everyone " if I could touch them" and stated if anyone refused the refusal would be honored. When asked if the guardians were contacted to give consent for the body inspections, staff #19 stated she didn't know; she "assumed it was done by someone else."

9. An interview was conducted with the Department of Human Services (DHS), Director of Regional Center Operations (DRCO) (responsible for oversight of all three Regional Centers) on 04/01/15 at 5:00 pm. The interview revealed that the activities of those two days occurred without clear necessity or identification of a specific allegation(s) of MANE. Further, the implementation of the wide-spread intrusion of the privacy for 62 people was not within the delineated or standard MANE investigation process as prescribed within regulation or agency policy (8.608.8 B7, B8, D 1-2).

a. The DRCO stated there were concerns that staff involved with mistreatment MANE were not terminated. However, she could not provide specific examples. She stated Adult Protective Services (APS) had contacted her supervisor with concerns that MANE were not being reported and the culmination of other concerns she could not or did not specify. There was concern within the sheriff ' s office regarding a specific deputy not ensuring appropriate follow-up was completed. "They are opening up some old cases he has closed out." She explained, "I am having some trust issues, really that's what is going on there. And I am not feeling comfortable that law enforcement has done their job; I am not comfortable that APS has been able to do their job. There just seems to be this handling internally-- but not really handling ...my concern is that there is more that hasn't been reported and I don't know how to get to that. But there are a lot of people that work at Pueblo that are related to one another - you know- fathers, daughters, different relatives working there."

When asked for the specific catalyst for the body inspections, she generally described or alluded to events such as an incident of paranormal activity; this included words appearing on a person's skin and "just abusive things happening." Note that the "paranormal" activity was reported to the Department of Public Health, the Pueblo Sheriff's Department and Adult Protective Services when it occurred in November 2014. According to the occurrence report from the PRC, no charges were filed and staff had been disciplined. Moreover, she stated while she did not have a list of specifics, her concerns were more anecdotal in nature and discussed an overarching mistrust of internal and external systems involving investigations of MANE.

b. The Director of Regional Center Operations (DRCO) said her instructions were to "have eyes on all 62 persons, and conduct skin assessments." She explained the intent was to ensure everyone was "o.k." She stated guardians were not contacted prior to the body inspections due to the "immediacy to act."

During the interview, the DRCO described instructions given to the Wheat Ridge Regional Center teams which included: "We would go in and do the skin assessment. We'd ask them if they felt safe. Ask them if there was anything they wanted to tell us." The instructions did not contain any direction to ensure the persons served understood what was happening (exposure of private body areas); they or their guardians were not given the express opportunity to accept or decline the inspections. She explained the Wheat Ridge teams were asked to "obtain staff [PRC] permission for people who were non-verbal." However, it should be noted, PRC staff do not have the authority to speak or give consent on behalf of the persons served (see definition of authorized representative under Agency Policy 1.4 Rights of Persons Receiving Services).

c. Throughout the interview, the Director of Regional Center Operations (DRCO) could not specifically address why the Department of Human Services (DHS) felt it was necessary to conduct body inspections without defining scope, such as alleged staff involved, homes, or affected persons served, in which to focus their investigations. The Director of Regional Center Operations was specifically asked, " How did you decide to look at everyone? For example, when an allegation is received, it is typical, as you know, to look at that house, or that person, or that staff. So, how did you decide to look at everyone at PRC? " She replied by stating, " Because I wanted to ensure that everyone was safe. You know, I was just really concerned that I needed to see everyone. " She would not, or could not, directly answer the question or provide specific allegations of MANE meriting a body inspection for all 62 persons served. She provided no examples of one or more predators having access to, and inappropriate contact with, all ten residential settings and day program, which are separated by geographical location.

d. PRC ' s policy (Policy 1.4.A2), which is reflective of regulation (see above) required the procedure for a MANE investigation to include: (A.1.) the allegation is immediately reported to the emergency on call staff; (A.2.) the employee notifies the primary nurse or nurse on duty in the event of an injury or allegation of physical abuse; (A.3.) the employee calls the hotline number; (A.4.) the employee completes an incident report prior to the end of his/her shift; (A.4.) the employee documents all proactive actions taken on the incident report, and (A.4.) forwards to the Quality Assurance Director; (A.5.) information is disclosed to law enforcement or other regulatory agencies in any case of suspected abuse. In the course of the interview, the Director of Regional Center Operations (DRCO) did not, or could not, provide any evidence that these steps had been followed when the initial allegations were identified.

Further, in accordance with Policy 1.4.A2, the Department of Human Services (DHS) failed to adhere to the investigative steps and expectations within PRC ' s policy as they proceeded. Specifically, B.1., states: " follow any instructions provided by the emergency on call or nurse on duty due to possible injury. " However, interview with the Director of Regional Center Operations (DRCO) did not reveal any specific allegations of possible injury were occurring and provided no information of a possible catalyst for the widespread body inspections of 62 persons served.

Additionally, the policy did not provide for authority to disregard each person ' s right for opportunity to have informed consent, and to observe their right for privacy, dignity and respect. In fact, according to Policy 1.4.A2, any victims of possible abuse shall be treated " with dignity and respect " while individual safety is also assured. State licensing rules 6 CCR 10-1011, Ch II 6.104 (see above) also require that each individual and their designated representative has the right to participate in all decisions involving their care or treatment; to receive care and treatment that is respectful and dignified, provides for personal privacy, and; give informed consent for all treatment and procedures and assure care is delivered in accordance with the needs of the individual.

10. Document review showed that although PRC had a written policy, there was no provision for the oversight or insertion of DHS staff into the agency ' s MANE investigation process. Nor were there overarching policies or procedures that DHS could provide that allowed DHS to alter the process in which MANE would be investigated at the PRC (8.608.8 B7 and B8).

On 04/07/15, both the PRC Executive Director and the Director of Regional Center Operations (DRCO) were asked (individually) for policies and procedures for governance of the regional centers by the Department of Human Services (DHS) and more specifically, the Pueblo Regional Center; neither could provide evidence of the policy. On 04/09/15 (two days later), the DRCO sent an informal document that she assembled after the policy was requested - the document was a cut and paste from the statute [24-1-120] that established the Department of Human Services with an additional paragraph stating: "The Colorado Department of Human Services is an Executive Branch agency. Its Executive Director is appointed by the Governor of the state of Colorado and serves as a member of the Governor's Cabinet. The DRCO reports to the Director of the Office of Community Access and Independence, who then reports to the Department of Human Services Executive Director." According to the DRCO, " the Regional Centers have never been asked for this policy before, therefore did not have one written. It was written and put into place upon your [CDPHE] bringing it to our attention. "

Notably, no policy was provided which authorized DHS to override the PRC policy in regards to MANE allegations, investigations and individual rights. Moreover, there was no policy to identify procedures in which DHS established their ultimate authority and legal responsibility for the management and operation of PRC (6 CCR 10-1011, Ch. VIII-2.5; see above).

In summary, body inspections were conducted by state personnel under the express direction of the Department of Human Service (DHS) officials. DHS provided no regulation, policy or procedure that allowed for the wide-spread inspection of all persons ' bodies. There was no evidence of specific allegations of physical or sexual abuse across eleven different settings separated by geographical location. Moreover, there was no provision in the directions given by DHS to ensure individuals were informed of the scope of the inspections and given opportunity to provide consent prior to implementation of the inspections. For the 40 individuals who were unable to provide consent, guardians were not notified nor consulted as required by regulation and PRC policy. Although the interview with the Director of Regional Center Operations stated notifications of guardians were not made due to the " immediacy to act ", no evidence of the need to act with immediacy was ever established. There was no evidence to support the DHS' actions which resulted in disregard of individual rights including privacy, dignity and respect. These actions resulted in individuals being scared and confused and some remained agitated days after the inspections took place.





Facility Plan of Correction:

D301

1. The plan for correcting the specific deficiency

The Colorado Department of Human Services (CDHS) disputes the statement under Tag 301 that CDHS did not have specific justification for conducting physical wellness checks at the Pueblo Regional Center (PRC). CDHS intervened to protect PRC residents from mistreatment, abuse, neglect and exploitation (MANE) for the following reasons:
A. In February 2015, CDHS first learned of PRC’s potential deficiencies in responding to MANE through two key incidents.
• Around the weekend of November 7, 2014, PRC staff found threatening words scratched into the back and stomachs of non-verbal residents. Review of the incident led CDHS to suspect PRC had not responded to or investigated this incident properly. PRC management did not move staff from the residence in question to ensure resident safety, did not report the incident to Pueblo County Adult Protective Service, and did not report the incident to law enforcement for nearly one month. CDHS’s review indicated PRC staff had violated PRC policies in failing to report MANE, failing to conduct timely physical wellness checks on residents involved, and failing to take appropriate personnel action. CDHS was particularly concerned that the PRC Director did not consider the November 2014 incidents a “critical incident” triggering higher-level reporting to CDHS, and that the Pueblo County Sheriff’s Office had listed its investigation of the incident as “inactive,” with no charges filed, since late December 2014.
• On February 19, 2015, two residents stole a staff vehicle and eloped from PRC. The two residents had been unsupervised when they fled. One of the residents was under an individualized plan that prohibited unsupervised time, and required line-of-sight supervision in the community. PRC staff had failed to immediately report the elopement to the PRC Director.

B. Over March 2015, CDHS discovered repeated failures by PRC to report or investigate allegations of MANE. Through conversations with other external investigative agencies, CDHS learned of additional instances of alleged MANE that PRC had not properly reported or investigated:
• During an external agency’s investigation into suspected abuse of a resident, PRC staff appeared to have dressed the resident in inappropriately heavy, long-sleeved clothing in order to cover markings or bruises, and the resident appeared scared to talk to the agency’s investigator.
• In two recent investigations of alleged verbal and physical abuse, including staff reportedly threatening to kill a resident, PRC management put both employees allegedly involved in the incidents back to work from administrative leave before the external agency’s investigator could conclude his investigation. The external agency investigator reported that certain PRC management and staff failed to cooperate with and actively thwarted his investigation, including PRC staff refusing to provide requested evidence. The external investigative agency believed PRC management may have obstructed other investigations as well, and observed that PRC reported unusually few MANE allegations relative to other facilities of comparable size.
• A second investigative agency recently determined that one of its employees had failed to properly investigate multiple alleged incidents of MANE, including allegations that PRC staff verbally and physically abused residents by striking, choking, shoving, or humiliating residents, refusing to clean or provide water to residents, and theft of resident medication. The second external investigative agency noted that many of the allegations could support criminal charges, but its employee had agreed with PRC management to let PRC handle the incident “internally,” with no charges filed. The second external investigative agency also had learned of alleged retaliation by PRC management against staff who reported MANE.
• As of June 17, 2015, the Pueblo Sheriff’s Office announced in a press release that it is seeking charges against seven current or former PRC staff based on the above allegations.

C. The above allegations of MANE, taken together, involved PRC residents who lived in, and staff who had duties in, all ten group homes and the Day Program. The systemic concern that PRC management inadequately reported or investigated MANE and inadequately disciplined staff involved meant residents across PRC were at risk for ongoing undiscovered or unreported MANE. Based on the foregoing, CDHS had a significant factual basis to believe PRC residents in all ten group homes and the Day Program were subject to an unacceptable and imminent risk to their health and safety prior to the unannounced visit to PRC on March 25 and 26, 2015.

With respect to the cited deficiency under 6 C.C.R. 1011-1 Chapter 8 § 4.1, CDHS has established a Governing Body Policy that defines CDHS, through the Division of Regional Center Operations (DRCO), as the governing body for the Pueblo Regional Center (PRC), describes the body’s authority and responsibility for Regional Center operations, and provides for the oversight of the Regional Centers, including authority to perform emergency interventions. This policy (Policy No. I) applies to all the Regional Centers.

Policy No. I authorizes CDHS to intervene in Regional Center investigations and to alter the process of those investigations, as follows: the Colorado Department of Human Services retains ultimate responsibility and authority to ensure resident health and safety, operational compliance with statute, rule, and policy, and overall implementation of best practices. In exercise of this authority, the Division Director may, either outside or in conjunction with Regional Center administration, require the Regional Center to submit to audit or inspection by CDHS staff or other federal or state regulatory authority. In case of an imminent threat to resident health and safety, the Division Director may take necessary emergency protective measures within federal and state law, but will take reasonable efforts to align those measures with Regional Center administration and policy. Prior to taking emergency measures, the Division Director will develop a plan of action including an identification of the concerns requiring emergency intervention, the scope of the planned investigation, including specific information on residents that may be contacted, group homes or programs that will be included in the review, and a plan of parent or guardian contact appropriate to ensuring the integrity of the investigation and the protection of residents.


2. The procedure for implementing the plan of correction

CDHS developed Policy No. I with input and approval from the Office of Community Access and Independence (OCAI), the DRCO Director, and the PRC Interim Director. These individuals are educated regarding the policy. This policy is complete in substance, and is under review by executive management. The policy will be finalized within two business days after this Plan of Correction is approved by CDPHE. Because CDHS’s investigation resulted in several staff resignations or administrative leave, certain administrative staff will be educated on the policy upon hire or return to their designated positions.


3. The monitoring procedure to ensure the plan of correction is effective and the deficiency remains corrected

The OCAI and DRCO will continue to review and evaluate the governing body policy as it is implemented by, among other measures, seeking input from the Regional Centers’ administration. PRC’s new Quality Assurance and Performance Improvement (QAPI) Committee will review the effectiveness of this policy as it is implemented, relying on the Quality Assurance Office staff (QA) to report resident and staff concerns. This committee will meet monthly to monitor and assess outcomes and trends within PRC. The committee shall make recommendations to improve resident quality of life through additions or revisions to the Governing Body Policy, as appropriate. The DRCO shall review such recommendations in evaluating the effectiveness of the Governing Body Policy and will update the policy as needed.


4. The title of the person(s) responsible for implementing the plan of correction

The OCAI Director and DRCO Director will be involved in reviewing and approving future updates to the Governing Body Policy, with input from the PRC Director. PRC’s QAPI Committee shall consist of QA staff, the PRC Director, the Director of Nursing/Infection Control Nurse, the Program Services Director, Direct Care Staff, and a Safety Representative. Other participants may include an Environment/Facilities Representative, the Health Services Director/Medical Director, Occupational Therapist, and other members as deemed appropriate.


5. Date of completion: 6/26/2015, to be finalized within two business days after this Plan of Correction is approved by CDPHE. Ongoing training will follow and be completed by 7/24/2015.


D303

1. The plan for correcting the specific deficiency

The Colorado Department of Human Services (CDHS) disputes the statement under Tag D303 that CDHS violated Pueblo Regional Center (PRC) policies on MANE by conducting wellness checks of residents without informed consent and immediate guardian notification. The statutes and rules that govern residents’ right to informed consent do not require informed consent for wellness checks to investigate suspected MANE. Additionally, physical wellness checks were conducted only on residents who gave permission for the checks. Twelve residents refused all or partial physical wellness checks; residents’ right to refuse the wellness checks were consistently honored. Further, PRC notified all guardians or parents of any findings within 24 hours and all other guardians or parents within the week following the site visit at PRC.
CDHS admits that, while it had a monitoring system that was not recorded in policies, this system did not detect the serious threats to PRC resident health and safety, and the cited deficiency under 6 C.C.R. 1011-1 Chapter 8 § 4.3 is generally appropriate.

CDHS has established a Governing Body Policy (Policy No. I) that provides for monitoring and reviewing the medical care and health of PRC residents through regular oversight of PRC’s operations. The Division of Regional Center Operations (DRCO) Director may, either outside or in conjunction with Regional Center administration, require the Regional Center to submit to audit or inspection by CDHS staff or other federal or state regulatory authority. At least twice per year, the Division Director, and if applicable other CDHS staff, shall make unannounced visits at each Regional Center to ensure operational compliance with statute, rule, and policy.

The same policy requires regular meetings between Regional Center administration and the DRCO and enumerates four agency-level policies that require timely reporting to the DRCO regarding any potential threats to resident well-being. The Division Director shall rely on at a minimum: the individual Regional Center’s adherence to and outcomes of their QAPI Policy; adherence to and outcomes of the Occurrence Reporting Policy; adherence to and outcomes of Incident Reporting Policy; and adherence to and outcomes of the MANE Policy, in addition to periodic management team meetings both at the DRCO and individual Regional Centers.

PRC has established a Quality Assurance and Performance Improvement policy (the “QAPI Policy”) to provide clear, consistent, and effective practices through direct and continuous monitoring, analysis of trends, and recommendations for quality improvement. As detailed in the policy, the QAPI committee will meet monthly to review data such as incident reports, medication and nutrition variances, and other concerns in order to identify trends and develop processes and new approaches to fix identified problems. The QAPI committee will document its actions in reports and minutes, and its outcomes will be communicated to the DRCO Director according to the Governing Body Policy.

In addition, CDHS and PRC reviewed and will re-issue PRC Policies Nos. 1.4 (Rights of Persons Receiving Services), 1.5.A1 (Emergency on Call Duty Officer), 1.5C1h (Human Rights Policy and Human Rights Committee Procedure), and 1.5.I1 (Incident Reporting). The updated policies—respectively, nos. 1.4a, 1.5.A1a, 1.5.C1i, and 1.5.I1a—enhance the oversight of PRC and its group homes and Day Program. These policy updates improve both internal oversight, through detailed staff workflows for critical and non-critical incidents, and external oversight, through reporting to parents or guardians, law enforcement, and the third-party advisory Human Rights Committee (HRC). In particular, the HRC will assist the PRC Director in monitoring resident medical care and health, allegations of abuse and neglect, and civil rights.

Under these policies, all critical incidents, including all allegations of mistreatment, abuse, neglect or exploitation (MANE), will be communicated to CDHS executive management within 24 hours of receipt of incident report. In addition, each critical incident will trigger a review by the QAPI committee as well as reporting to the Community Centered Board (CCB) and the HRC, which are external to PRC’s administration. The policies also require every critical incident investigation and outcome to be documented in a Quality Assurance (QA) file. In addition, the PRC Director will communicate outcomes to CDHS or DRCO as the governing body according to the Governing Body Policy, through periodic meetings, and biannual and as-needed inspections.

In concert, these policies explicitly provide that CDHS will oversee and monitor the operations of PRC and its group homes and the Day Program, including direct and continuous monitoring of the medical care, health, and alleged MANE, and timely reporting of critical incidents (including alleged MANE) to the governing body.


2. The procedure for implementing the plan of correction

CDHS developed Policy No. I with input and approval from the Office of Community Access and Independence (OCAI), the DRCO Director, and the PRC Interim Director. These individuals are educated regarding the policy. Because CDHS’s investigation resulted in several staff resignations or administrative leave, certain administrative staff will be educated on the policy upon hire or return to their designated positions. PRC developed the QAPI Policy and updated Policy Nos. 1.4a, 1.5.A1a, 1.5.C1i, and 1.5.I1a with input and approval from the OCAI and DRCO. The MANE policy (Policy No. 1.4.A2) and incident workflows are being revised to reflect changes in reporting structure to the Community Centered Board (CCB) effective July 1, 2015, improvements made to the internal process, and clarifications to the definition of critical and non-critical incidents. These policies and policy revisions are complete in substance, and are under review by executive management. They will be finalized within two business days after this Plan of Correction is approved by CDPHE.

All staff were educated regarding the then-current MANE policy and investigation as of 5/7/15. Emergency on-call and administrative staff were educated on the incident workflows on 5/7/15. All staff will be educated on the revised policies and incident workflows beginning 6/29/15, pending final approval of this Plan of Correction by CDPHE. This education will be provided upon hire, annually, and as needed. Training will be completed by 7/24/15.


3. The monitoring procedure to ensure the plan of correction is effective and the deficiency remains corrected

All incident reports have been reviewed daily Monday through Friday by an outside consulting agency, beginning 5/14/15 and continuing as needed, as part of the quality assurance process to determine compliance with PRC policy and state occurrence reporting rules for all MANE investigations. PRC’s QA staff will continue the Monday through Friday reviews of all incident reports. QA staff and, as necessary, the QAPI committee or the PRC Director will address any identified deviation from policy or state occurrence reporting rules with the responsible staff and supervisor. At least twice per year, the DRCO Director, and if applicable other CDHS staff, shall make unannounced visits to PRC to ensure operational compliance.

PRC shall complete an initial evaluation of the QAPI Policy’s effectiveness within the first year of implementation. The QAPI committee will develop a further action plan for any identified concerns, if needed, until compliance is achieved.


4. The title of the person(s) responsible for implementing the plan of correction

The DRCO and PRC Directors are generally responsible for ensuring communication about operations and outcomes between PRC and CDHS. With respect to the continuous monitoring of resident well-being, the QA staff and QAPI committee have primary responsibility for reporting and analyzing the data. The QA staff tracks results of incident report reviews in a database and these results are reviewed in the monthly QAPI committee and weekly management meetings. For each critical incident (including alleged MANE), PRC’s Emergency On-Call staff has primary responsibility to notify the parent or guardian, law enforcement, and CCB, and the PRC Director is responsible for notifying CDHS executive management.


5. Date of completion: 6/26/2015, to be finalized within two business days after this Plan of Correction is approved by CDPHE. Ongoing training will follow and be completed by July 24, 2015.


D526

1. The plan for correcting the specific deficiency

The Colorado Department of Human Services (CDHS) disputes the statement under Tag 526 that CDHS violated Pueblo Regional Center (PRC) residents’ rights to informed consent. Colorado statutes and rules do not require informed consent or guardian consent for routine care and treatment or for investigation of mistreatment, abuse, neglect, and exploitation (MANE). The right to written, informed consent applies to certain unusual forms of care and treatment that are invasive, surgical, or irreversible; it does not require prior guardian consent or a signed consent form for each and every routine caregiving act. The right to informed consent does not require prior guardian consent or a signed consent form in order for CDHS to fulfill its obligation to carry out mandatory investigations of alleged MANE. Such a broad informed consent requirement would undermine CDHS’s ability to protect residents’ health and safety against imminent threats and its compliance with the law.

CDHS performed the physical wellness checks of PRC residents for the sole purpose of investigating grave concerns regarding suspected MANE. Trained medical professionals conducted the physical wellness checks within the parameters of their specialized training and experience, and within acceptable standards in the field. Staff introduced themselves to each resident and explained that they were at PRC to determine whether the residents were safe, and to check the residents for injuries.

Residents were given the opportunity to decline or stop the physical wellness checks, and the medical professionals conducting the checks continually assessed for any indication that the resident was uncomfortable. These professionals confirmed to CDHS that, if the examiner noted any discomfort, including nonverbal signs of discomfort, the examiner either asked the resident if he or she was comfortable with proceeding, or ended the physical wellness check. All physical wellness checks were performed in privacy, either in the resident’s bedroom or behind a privacy screen. If the resident was already being assisted by PRC staff with showering or dressing, the wellness checks were done in conjunction with those activities to avoid disruption of the resident’s daily activities.

CDHS further disputes the statement that CDHS violated rules concerning parent or guardian notification. CDHS complied with laws regarding notification to parents and guardians. The physical wellness checks revealed 10 suspected incidents of MANE, and CDHS notified the parents or guardians of the affected residents within 24 hours of the discovery. Allegations of MANE that precipitated CDHS’s wellness checks at PRC had previously been reported to parents or guardians, where CDHS and PRC had sufficient information (including identity of the resident affected) to make the notification.

With respect to the cited deficiencies under 6 C.C.R. 1011-1 Chapter 8 § 9.1 and 10 C.C.R. 2505-10 § 8.604.1, CDHS did have written policies and procedures on resident rights which address the rights set forth in 6 C.C.R. 1011-1 Chapter 2, Part 6, and §§ 25.5-10-218 through 231, C.R.S. (2014). CDHS admits PRC’s resident rights policy, Policy No. 1.4, did not reproduce these statutes and rules exactly, and has made sure the revised Policy No. 1.4a tracks statutory and rule language almost exactly, with only minimal changes necessary to adapt language to PRC’s operations. PRC revised Policy No. 1.4, Rights of Persons Receiving Services to enumerate the specific rights in 6 C.C.R. 1011-1 Chapter 2 § 6.104 (patient rights policies) and §§ 25.5-10-218 through 231, C.R.S. Now recorded as Policy No. 1.4a, PRC’s resident rights policy explicitly articulates each of the guarantees in the above-cited rule and statutes and specifies procedures to promote them, such as posted notices to assist in making complaints to external entities.

PRC’s QAPI Policy and revised Policy No. 1.5.C1i, among others, specify procedures to ensure the above rights are protected and promoted. Among other data reviewed monthly, the QAPI committee will review basic assurances, i.e., the fundamental safeguards related to health, safety and the promotion of person-centered values. Policy No. 1.5.Cli provides that the Human Rights Committee (HRC), which is external to PRC’s administration, will review PRC staff’s practices for compliance with statute, rule, and policy regarding resident rights, including the rights to informed consent, due process, limitations on the use of restraints and behavior-modifying medication, and freedom from MANE.

While CDHS disputes the assertion that it was required to obtain written informed consent prior to conducting a MANE investigation, to ensure that there are no further consent misunderstandings, CDHS will establish an advisory group to develop recommendations for a standardized consent process. The advisory group will include stakeholders, including parents, guardians and residents, to advise on refinements to the consent process, with a plan to have a final process in place for all Regional Centers by 8/1/15. In the interim, CDHS will take any necessary and immediate actions to ensure the safety and well-being of residents in emergency or exigent situations involving allegations of resident abuse or neglect. Parents or guardians will be notified of allegations of abuse and neglect, and actions taken by CDHS in response to any such allegations, as soon as practicable under the circumstances.


2. The procedure for implementing the plan of correction

PRC developed the Quality Assurance and Performance Improvement (QAPI) Policy and updated Policy Nos. 1.4a and 1.5.C1i with input and approval from the Office of Community Access and Independence (OCAI) and Division of Regional Center Operations (DRCO). These policies will be finalized within two business days after this Plan of Correction is approved by CDPHE. All PRC staff received training and education on residents’ rights to dignity, respect, and protecting and promoting personal privacy as of 5/26/15. All PRC staff will be educated on the revised resident rights policy beginning 06/29/15, pending final approval of this Plan of Correction by CDPHE. All current staff will be trained on the revised resident rights policy by 7/24/15. Training will be provided by 8/31/2015 on the consent process that is planned for development by 8/1/15. The above education will be provided upon hire and annually, and as needed.


3. The monitoring procedure to ensure the plan of correction is effective and the deficiency remains corrected

The Community Centered Boards (CCB) will begin hosting the HRC as of July 1, 2015. The HRC shall meet at least monthly to review and make recommendations on, among other issues, residents’ exercise of informed consent, critical incidents, and PRC policies. Quality Assurance (QA) staff and, as necessary, the QAPI committee or the PRC Director will address any identified deviations from policy or rules regarding resident rights with the responsible staff and supervisor. At least twice per year, the DRCO Director, and if applicable other CDHS staff, shall make unannounced visits to PRC to ensure operational compliance and may order an inspection or audit as needed.

PRC shall complete an initial evaluation of the QAPI Policy’s effectiveness within the first year of implementation. The QAPI committee will develop a further action plan for any identified concerns, if needed, until compliance is achieved.


4. The title of the person(s) responsible for implementing the plan of correction

The PRC staff liaison to the HRC has primary responsibility for assisting the HRC in its duties. PRC’s QAPI Committee shall consist of QA staff, the PRC Director, the Director of Nursing/Infection Control Nurse, the Program Services Director, Direct Care Staff, and a Safety Representative. Other participants may include an Environment/Facilities Representative, the Health Services Director/Medical Director, Occupational Therapist, and other members as deemed appropriate. The PRC Director and administrative staff are responsible for ensuring the completion of trainings and education of PRC staff.


5. Date of completion: The Resident Rights Policy will be revised by 6/26/2015, to be finalized within two business days after this Plan of Correction is approved by CDPHE. Ongoing training will follow and be completed by July 24, 2015. The consent process will be developed by 8/1/2015 and training will be provided by 8/31/2015.


D542

1. The plan for correcting the specific deficiency

The Colorado Department of Human Services (CDHS) disputes the statement under Tag 542 that CDHS did not have specific justification for conducting physical wellness checks at the Pueblo Regional Center (PRC). CDHS intervened to protect PRC residents from mistreatment, abuse, neglect and exploitation (MANE) for the following reasons:

A. In February 2015, CDHS first learned of PRC’s potential deficiencies in responding to MANE through two key incidents.
• Around the weekend of November 7, 2014, PRC staff found threatening words scratched into the back and stomachs of non-verbal residents. Review of the incident led CDHS to suspect PRC had not responded to or investigated this incident properly. PRC management did not move staff from the residence in question to ensure resident safety, did not report the incident to Pueblo County Adult Protective Service, and did not report the incident to law enforcement for nearly one month. CDHS’s review indicated PRC staff had violated PRC policies in failing to report MANE, failing to conduct timely physical wellness checks on residents involved, and failing to take appropriate personnel action. CDHS was particularly concerned that the PRC Director did not consider the November 2014 incidents a “critical incident” triggering higher-level reporting to CDHS, and that the Pueblo County Sheriff’s Office had listed its investigation of the incident as “inactive,” with no charges filed, since late December 2014.
• On February 19, 2015, two residents stole a staff vehicle and eloped from PRC. The two residents had been unsupervised when they fled. One of the residents was under an individualized plan that prohibited unsupervised time, and required line-of-sight supervision in the community. PRC staff had failed to immediately report the elopement to the PRC Director.

B. Over March 2015, CDHS discovered repeated failures by PRC to report or investigate allegations of MANE. Through conversations with other external investigative agencies, CDHS learned of additional instances of alleged MANE that PRC had not properly reported or investigated:
• During an external agency’s investigation into suspected abuse of a resident, PRC staff appeared to have dressed the resident in inappropriately heavy, long-sleeved clothing in order to cover markings or bruises, and the resident appeared scared to talk to the external agency’s investigator.
• In two recent investigations of alleged verbal and physical abuse, including staff reportedly threatening to kill a resident, PRC management put both employees allegedly involved in the incidents back to work from administrative leave before the external agency’s investigator could conclude his investigation. The external investigator reported that certain PRC management and staff had failed to cooperate with and actively thwarted his investigation, including PRC staff refusing to provide requested evidence. The external investigative agency believed PRC management may have obstructed other investigations as well, and observed that PRC reported unusually few MANE allegations relative to other facilities of comparable size.
• A second investigative agency recently determined that one of its employees had failed to properly investigate multiple alleged incidents of MANE, including allegations that PRC staff verbally and physically abused residents by striking, choking, shoving, or humiliating residents, refusing to clean or provide water to residents, and theft of resident medication. The second external investigative agency noted that many of the allegations could support criminal charges, but its employee had agreed with PRC management to let PRC handle the incident “internally,” with no charges filed. The second external investigative agency also had learned of alleged retaliation by PRC management against staff who reported MANE.
• As of June 17, 2015, the Pueblo Sheriff’s Office announced in a press release that it is seeking charges against seven current or former PRC staff based on the above allegations.

C. The above allegations of MANE, taken together, involved PRC residents who lived in and staff who had duties in all ten group homes and the Day Program. The systemic concern that PRC management inadequately reported or investigated MANE and inadequately disciplined staff involved meant residents across PRC were at risk for ongoing undiscovered or unreported MANE. Based on the foregoing, CDHS had a significant factual basis to believe PRC residents in all ten group homes and the Day Program were subject to an unacceptable and imminent risk to their health and safety prior to the unannounced visit to PRC on March 25 and 26, 2015.

CDHS has clarified its authority to intervene in PRC operations and investigations, depart from facility-level policy on MANE investigations, and utilize the expertise of CDHS staff external to PRC through the adoption of Policy No. I, the Governing Body Policy. In exercise of this authority, the Division of Regional Center Operations (DRCO) Director may, either outside or in conjunction with Regional Center administration, require the Regional Center to submit to audit or inspection by CDHS staff or other federal or state regulatory authority. In case of an imminent threat to resident health and safety, the Division Director may take necessary emergency protective measures within federal and state law, but will take reasonable efforts to align those measures with Regional Center administration and policy. Prior to taking emergency measures, the Division Director will develop a plan of action including an identification of the concerns requiring emergency intervention, the scope of the planned investigation, including specific information on residents that may be contacted, group homes or programs that will be included in the review and a plan of parent or guardian contact appropriate to ensuring the integrity of the investigation and the protection of residents.

CDHS has strengthened the reporting lines between the Regional Centers and CDHS through the issuance of this policy as well as updated Policy Nos. 1.5.A1a and 1.5.I1a, concerning the emergency on-call staff and critical incident reporting, and refined workflows for incident reporting. These enhanced reporting mechanisms will significantly reduce the likelihood that a large-scale CDHS intervention would become necessary in the future.

CDHS also disputes the premise that CDHS’s wellness checks violated resident rights to informed consent. CDHS disputes the premise that guardian consent was required prior to investigating suspected MANE. The right to written, informed consent applies to certain unusual forms of care and treatment that are invasive, surgical, or irreversible; it does not require prior guardian consent or a signed consent form for each and every routine caregiving act. The right to informed consent does not require prior guardian consent or a signed consent form in order for CDHS to fulfill its obligation to carry out mandatory investigations of alleged MANE. Such a broad informed consent requirement would undermine CDHS’s ability to protect residents’ health and safety against imminent threats and its compliance with the law.

CDHS performed the physical wellness checks of PRC residents for the sole purpose of investigating grave concerns regarding suspected MANE. Trained medical professionals conducted the physical wellness checks within the parameters of their specialized training and experience, and within acceptable standards in the field. Staff introduced themselves to each resident and explained that they were at PRC to determine whether the residents were safe, and to check the residents for injuries. At no time were “strip searches” performed on any PRC residents, and CDHS objects to the repeated use of this inflammatory and incorrect term.

Residents were given the opportunity to decline or stop the physical wellness checks, and physical wellness checks were conducted only on the residents who gave permission for the checks. The medical professional conducting the checks continually assessed for any indication that the resident was uncomfortable. These professionals confirmed to CDHS that, if the examiner noted any discomfort, the examiner either asked the resident if he or she was comfortable with proceeding, or ended the physical wellness check. Twelve residents refused all or partial physical wellness checks. All physical wellness checks were performed in privacy, either in the resident’s bedroom or behind a privacy screen. If the resident was already being assisted by PRC staff with showering or dressing, the wellness checks were done in conjunction with those activities to avoid disruption of the resident’s daily activities.

PRC has issued a revised Policy No. 1.4a, Rights of Persons Receiving Services. To avoid future confusion about resident consent to treatment, care, and MANE investigations, CDHS will establish an advisory group to develop recommendations for a standardized consent process. The advisory group will include stakeholders, including parents, guardians and residents, to advise on refinements to the consent process, with a plan to have a final process in place for all Regional Centers by 8/1/15.

In the interim, CDHS will take any necessary and immediate actions to ensure the safety and well-being of residents in emergency or exigent situations involving allegations of resident abuse or neglect. Parents or guardians will be notified of allegations of abuse and neglect, and actions taken by CDHS in response to any such allegations, as soon as practicable under the circumstances.

These policies and processes will further ensure all residents are treated with dignity and respect, and will be given necessary medical care and protection from MANE. Specifically, Policy No. 1.4a emphasizes residents’ right to refuse care. The consent process will clarify consent requirements for the provision of health care services and also physical examinations or assessments related to MANE. The resident rights policy will be reviewed with each resident and their guardian at the next scheduled IDT meeting. Once the new consent process is implemented, the process will be reviewed with residents and their guardians or parents.

With respect to any parent or guardians’ perception that PRC failed to notify them of a suspected concern of MANE, PRC notified guardians or parents of all suspected MANE discovered during the March 25-26, 2015 CDHS intervention, and CDHS is verifying former PRC administrators’ representations that they made required notifications for alleged MANE that took place prior to CDHS intervention. PRC has revised Policy Nos. 1.5.A1a and 1.5.I1a, which include refined staff workflows that clarify the obligation to report critical incidents, including all allegations of MANE, to the resident’s guardian or parent after immediate interventions, and to CDHS, per 6 CCR 1011-1 Chapter 8 § 9.2. This policy will be re-evaluated after development of the finalized consent process to ensure alignment.

With respect to PRC’s alleged failure to prevent MANE, the Quality Assurance and Performance Improvement (QAPI) Policy and revised Policy Nos. 1.5.A1a and 1.5.I1a will ensure robust mechanisms to detect, eliminate, and prevent MANE. In addition, Governing Body Policy No. I and revised Policy No. 1.5.C1i strengthen and clarify CDHS and the Human Rights Committee’s (HRC) oversight, respectively. HRC is external to PRC’s administration. As detailed herein, CDHS took immediate action when it became aware suspected MANE may have been under-reported or under-investigated. CDHS conducted an unannounced site visit, consistent with 6 C.C.R. 1011-1 Chapter 8 § 9.1, with qualified staff from Wheat Ridge Regional Center (WRRC) to conduct wellness checks of PRC residents. All 62 PRC residents were seen; however, physical wellness checks were conducted only on the residents who gave permission. As a result of the site visit and physical wellness checks, 10 reportable incidents of alleged MANE were identified, and CDHS timely reported each suspected occurrence to the Pueblo Sheriff’s Office, County Adult Protective Services, CDPHE, and the affected residents’ parents or guardians. CDHS placed a total of 17 PRC staff on administrative leave and immediately brought seasoned, highly qualified administrative, quality assurance, nursing, and social work staff into PRC from another CDHS facility to cover for vacancies and to assist with system and process improvements. CDHS also appointed an Interim Director with decades of expertise. CDHS continues to work cooperatively with the Pueblo Sheriff’s Office and County Adult Protective Services as they reopen investigations into prior MANE allegations and investigate new allegations. CDHS is in frequent, open communication with PRC’s residents, parents, and guardians regarding improvements and developments at PRC. CDHS’s Chief Medical Officer has visited PRC on several occasions to assess residents’ mental and emotional well-being, and has engaged outside clinical resources as needed.


2. The procedure for implementing the plan of correction

CDHS developed Policy No. I with input and approval from the Office of Community Access and Independence (OCAI), the DRCO Director, and the PRC Interim Director. PRC developed the QAPI Policy and updated Policy Nos. 1.4a, 1.5.A1a, 1.5.C1i, and 1.5.I1a with input and approval from the OCAI and DRCO. PRC revised its MANE policy (Policy No. 1.4.A2) and incident workflows to reflect changes in reporting structure to the Community Centered Board (CCB), an external community entity, effective July 1, 2015, improvements made to the internal process, and clarifications to the definition of critical and non-critical incidents. These policies and policy revisions are complete in substance, and are under review by executive management. They will be finalized within two business days after this Plan of Correction is approved by CDPHE.

All staff were educated regarding the then-current MANE policy and investigation as of 5/7/15. Emergency on-call and administrative staff were educated on the incident workflows on 5/7/15. All PRC staff will be educated on the revised policies and incident workflows beginning 06/29/15, pending final approval of this Plan of Correction by CDPHE. All staff received training and education on residents’ rights to dignity, respect, and protecting and promoting personal privacy as of 5/26/15. All staff will be educated on the revised resident rights policy and the role of the HRC beginning 06/29/15, pending final approval of this Plan of Correction by CDPHE. Training will be completed by 7/24/15. Staff will be trained by 8/31/15 on the new consent process that will be developed by 8/1/15.
The above education will be provided upon hire, annually, and as needed.


3. The monitoring procedure to ensure the plan of correction is effective and the deficiency remains corrected

The OCAI and DRCO will continue to review and evaluate the Governing Body Policy as it is implemented by, among other measures, seeking input from the Regional Centers’ administration. PRC’s new QAPI committee will review the effectiveness of this policy as it is implemented, relying on the Quality Assurance (QA) staff to report resident and staff concerns. DRCO shall complete an initial evaluation of Policy No. I’s effectiveness and policy review within the first year of implementation.

All incident reports have been reviewed daily Monday through Friday by an outside consulting agency, beginning 5/14/15 and continuing as needed, as part of the quality assurance process to determine compliance with PRC policy and state occurrence reporting rules for all MANE investigations. This will continue as needed as part of the quality assurance process to determine compliance with PRC policy and state occurrence reporting rules for all MANE investigations. PRC’s QA staff will continue the Monday through Friday reviews of all incident reports. The HRC will be hosted by the CCB beginning 7/1/2015 and shall meet at least monthly to review and make recommendations on, among other issues, residents’ exercise of informed consent, critical incidents, and PRC policies. QA staff and, as necessary, the QAPI committee or the PRC Director will address any identified deviations from policy or rules, especially those policies or rules regarding resident rights and MANE, with the responsible staff and supervisor. At least twice per year, the DRCO Director, and if applicable other DHS staff, shall make unannounced visits to PRC to ensure operational compliance and may order an inspection or audit as needed.

In addition, the CCB will independently review all critical incidents. The CCB staff will contact County Adult Protective Services and complete an independent investigation in conjunction with County Adult Protective Services. When the agencies complete their report, it will be forwarded to PRC QA staff. Any new recommendations will be addressed in the action plan for resolving the incident.

These internal and external review mechanisms will promote early detection and elimination of unauthorized deviation from policies, incident workflows, and resident rights standards.


4. The title of the person(s) responsible for implementing the plan of correction

The OCAI Director and DRCO Director will be involved in reviewing and approving future updates to the Governing Body Policy and adopting governing body by-laws, with input from the PRC Director.

The DRCO and PRC Directors are generally responsible for ensuring communication about operations and outcomes between PRC and CDHS. With respect to the continuous monitoring of resident well-being, the QA staff and QAPI committee have primary responsibility for reporting and analyzing data. The QA staff tracks results of incident report reviews on a database and these results are reviewed in the monthly QAPI committee and weekly management meetings. For each critical incident (including alleged MANE), the Emergency On-Call staff has primary responsibility to notify the parent or guardian, law enforcement, and CCB, and the PRC Director is responsible for notifying CDHS executive management.

The PRC Director and administrative staff are responsible for ensuring that PRC staff is trained and educated on these policies.

The PRC staff liaison to the HRC has primary responsibility for assisting the HRC in its duties.


5. Date of completion: 6/26/2015, to be finalized within two business days after this Plan of Correction is approved by CDPHE. Ongoing training will follow and be completed by July 24, 2015.


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Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
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Denver CO 80246-1530
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