FOR IMMEDIATE RELEASE June 26, 2015 (Denver, CO) – The Colorado Department of Human Services (CDHS) on Friday announced changes in policies and procedures at the Pueblo Regional Center in response to the Colorado Department of Public Health and Environment’s (CDPHE) findings from its review of complaints regarding the Pueblo Regional Center. The complete CDPHE investigation report, and CDHS’ corresponding response and plan of correction can be found on CDPHE’s web site. “Our overriding concern is, has been, and continues to be the safety of our Regional Center residents,” said Reggie Bicha, CDHS executive director. “The allegations of mistreatment, abuse, neglect and exploitation (MANE) we had received were very disturbing, and I felt we needed to take action to make sure residents were safe. We had significant factual basis to believe residents in all 10 group homes and the Day Program were subject to unacceptable and imminent risk to their health and safety.” CDPHE investigated complaints alleging policy violations occurred when resident health and wellness checks were conducted by CDHS in March. The review revealed that CDHS sent a cross-disciplinary team to review allegations of widespread abuse and neglect at the center by the center’s staff. As part of the review, the CDHS team conducted physical wellness checks on most of the center’s residents. “Following a complaint about the Pueblo Regional Center, we conducted a thorough investigation of the Center’s policies and procedures, including interviews with staff members, residents and guardians,” said Larry Wolk, executive director and chief medical officer, CDPHE. “From that investigation we identified four deficient practices and required the facility to develop a plan to comprehensively address each deficiency. Today, we accepted the Plan of Correction submitted by the Department of Human Services.” During February and March of this year, numerous concerning incidents were uncovered by the CDHS executive team that had been improperly reported or not reported at all to oversight agencies
including CDPHE, local law enforcement and county adult protective services. In addition, internal reporting processes were not consistently or thoroughly followed. These incidents included threatening words scratched into the backs and stomachs of non-verbal residents; two unsupervised residents who stole a vehicle; reports of staff striking, choking, shoving and humiliating residents; and theft of resident medication. Obviously these reports were so egregious and of such a serious nature that the safety of the residents was unknown and a thorough assessment of their medical well-being was necessitated. According to the Plan of Correction submitted by CDHS, residents were given the opportunity to decline or end the physical wellness checks, and medical professionals conducting the checks continually assessed residents for any indication they were uncomfortable. If the examiner noted any discomfort, including nonverbal signs of discomfort, the examiner either asked the resident if he/she was comfortable with proceeding, or ended the physical wellness check. All physical wellness checks were performed in private. During the course of the wellness checks, 12 residents refused all or part of the check, and in all cases, medical staff performing the checks honored their refusals. The physical wellness checks revealed 10 suspected incidents of resident maltreatment. CDHS notified parents or guardians of the affected residents within 24 hours of the discovery, and all other parents/guardians within the week following the site visit at PRC. As a result of the physical wellness checks, several cases were referred to the Pueblo Sheriff’s Office for investigation. Earlier this month, Sheriff Kirk Taylor announced that he is seeking charges against seven current or former Pueblo Regional Center staff who were involved in six cases of abuse, neglect or sexual misconduct/abuse. Of the seven PRC employees involved in those criminal cases, none of them is still working at the Pueblo Regional Center. Three remain on paid administrative leave and the other four are no longer in the employment of CDHS. “Due to the significance and severity of the allegations that had come to our attention, we needed to take swift action to ensure the safety and well-being of our residents. However, in hindsight, I wish we would have engaged the parents and guardians sooner,” said Bicha. In response to the CDPHE findings, CDHS has established a Quality Assurance and Performance Improvement (QAPI) policy to provide clear, consistent and effective practices through direct and continuous monitoring, analysis of trends, and recommendations for quality improvement. The QAPI committee established under the new policy, will meet monthly to review data, including incident reports, medication and nutrition variances, and other concerns in order to identify trends and develop processes and new approaches to fix identified problems. In addition, all critical incidents, including allegations of mistreatment, abuse, neglect or exploitation will be communicated to CDHS executive management within 24 hours of receipt of an incident report. Each critical incident will trigger a review by the QAPI committee as well as reporting to the Community Centered Board (CCB) and the Human Resources Committee, both of which are external to PRC’s administration. At least twice per year, the Division of Regional Center Operations Director, and, if applicable, other CDHS staff, will make unannounced visits to PRC to ensure proper operational compliance. CDHS takes seriously its legal, ethical and moral obligations to ensure the safety, health and well-being of the men and women who reside in the three Regional Centers. CDHS is also committed to engaging guardians and family in planning, care and interventions for Regional Center residents. CDHS affirms its responsibility to detect, prevent and investigate when Regional Center residents are suspected of being
mistreated in any way. In furtherance of this responsibility, CDHS is developing a standardized consent process which will be implemented at all three Regional Centers. Under the proposed standardized process, CDHS will seek to provide advance notice and then obtain consent from legal guardians before physical or medical interventions are pursued in matters involving MANE. There may be certain emergency or exigent situations involving allegations of resident abuse or neglect where CDHS may not be able to give advance notice and obtain consent. In those cases, CDHS will take any necessary and immediate actions to assure the safety and well-being of residents, and parents or guardians will be notified of allegations of abuse and neglect, and actions taken by CDHS, as soon as practicable under the circumstances. In addition, CDHS will convene a group of stakeholders, including parents, guardians, and residents to advise on refinements to the standardized consent process, with a plan to have a final process in place for all Regional Centers by August 1, 2015. “Both Departments are committed to the well-being and treatment of each of the residents who have been entrusted to our care,” said Bicha. “The Regional Centers play an important role in the continuum of care for developmentally and intellectually disabled Coloradans, and we are dedicated to ensuring the Regional Centers’ stability and ongoing operations now, and into the future.” “We will be following up with CDHS and the Pueblo Regional Center to ensure ongoing compliance with their plan of correction, and to ensure the proper care for the residents who call the regional center home,” added Wolk. -
To find the materials on CDPHE’s web site: Click on the link provided http://www.hfemsd2.dphe.state.co.us/hfd2003/facfind.aspx Enter the address of the facility. When you get to the facility's page, click the 4/22/2015 Complaint Survey under the Health Survey section.
Facility addresses: 1. 198 E Galatea 2. 262 S Bayfield 3. 268 Harmony Drive 4. 272 Harmony Drive 5. 330 E Hahns Peak 6. 416 E Maher Drive 7. 496 S Latimer 8. 614 S Clarion 9. 887 S Bellflower 10. 895 S Bellflower 11. Direct Service PRC You’ll find that the CDPHE report and CDHS Plan of Correction are the same for each address. The Direct Service PRC, is slightly different.