SERIOUS OCCURRENCE QUESTIONS

Colorado HCBS-DD 0007 Pueblo Regional Center

1. GENERAL OCCURRENCE QUESTIONS:

A. Describe the nature and scope of the issue/incident(s)?
On March 30, 2015, the Colorado Department of Public Health and
Environment (DPHE) received 10 complaints from guardians and residents of
Pueblo Regional Center alleging that the Colorado Department of Human
Services (DHS) conducted comprehensive unclothed physical assessments of
62 residents in 10 individually licensed and certified Group Homes and one
Day Habilitation program at Pueblo Regional Center (PRC). The PRC is
operated by DHS, providing services and supports to individuals enrolled in
the Home and Community Based Services for Persons with Developmental
Disabilities (HCBS-DD) waiver, # CO.0007. This waiver serves adults 18 years
of age and older.
a. When did it happen?
The comprehensive unclothed physical assessments occurred on March
25, 2015 and March 26, 2015.
b. How did it happen?
The DHS developed a cross disciplinary team from Wheat Ridge
Regional Center (WRRC) to conduct a site visit and wellness checks of
all 62 residents at PRC due to suspected risks of abuse, neglect, and
other mistreatment of residents. The wellness checks included a head-

to-toe skin examination by a medical professional, with a witness

present.
c. Who was impacted?
All 62 residents of the PRC were assessed by the team from WRRC and
12 of these individuals refused either all or partial examination. 50
residents received a full examination.
d. Where did it happen?
The site visit and comprehensive unclothed physical assessments were
completed at all 10 Group Homes of PRC as well as the Day
Habilitation program which is located at 270 W. John Powell Boulevard,
Pueblo West, Colorado 81007.
Day Habilitation Program site
9 residents
Individual Group Homes
41 residents
B. How and when did HCPF learn about the issue?
The Department of Health Care Policy and Financing (DHCPF) learned some
general and incomplete information during a meeting of the Regional Center
Task Force on April 20, 2015, when two documents were distributed to Task
Force members. One document was a copy of a resignation letter from the
Director of Pueblo Regional Center. This letter provided some information
about the issue. The second document was a copy of a letter from the
Director of DHS, Division of for Regional Center Operations (DRCO),
informing parents and guardians about the issue. The DHCPF did not
understand the scope of the problem until April 24, 2015.
The DHCPF was informed directly by DHS staff of the site visit and
comprehensive unclothed physical assessments through email on April 24,
2015.
Appendix 1 provides the letter sent to the parents and guardians.
C. Does the occurrence involve waiver participants?
Yes, all individuals involved are enrolled in the HCBS-DD waiver, # CO.0007.
a. What population?

All individuals involved have a diagnosis of an Intellectual and/or

Developmental Disability.
b. Which waivers?
All individuals involved are enrolled in the HCBS-DD waiver, #
CO.0007.
c. How many individuals?
62 residents of PRC.
d. How many waiver homes (if applicable)?
There are 10 individually licensed and certified Group Homes at PRC.
D. Who are the participants?
The participants are inclusive of all residents of PRC.
a. (Are there potentially other Medicaid clients impacted even
though they were not a part of the initial report?)
No, the 62 residents who received the comprehensive unclothed
physical assessments are the only Medicaid clients impacted.
E. What is known about the occurrence (What is the issue, when and
where did it occur)?
On March 25, 2015 and March 26, 2015, a cross disciplinary team developed
by DHS consisting of staff from WRRC completed a site visit to conduct
wellness checks of all residents at PRC in each of the 10 Group Homes and
one Day Habilitation program. During this site visit, 62 individuals were
observed. Out of the 62, 12 individuals partially or fully refused the
assessment; therefore 50 individuals had a complete head-to-toe skin
assessment.
On March 30, 2015, the DPHE received ten complaints from family members,
guardians and individuals receiving services alleging that the DHS conducted
comprehensive unclothed physical assessments on 62 residents of PRC.

F. Are State employees providing direct care services? If yes, are

there any potential employment issues related to State employment
that could impact the outcome of this issue? Has any staff resigned
related to the alleged occurrence?
Yes, state employees are providing direct care services. As of the date of this
report, the Director for the PRC resigned and one additional staff (a nurse)
has resigned. Personnel actions are being handled within the guidelines of
the State Personnel Rules.
G. What has been done to date to protect the participant(s)?
The DHS placed the Director, Assistant Director, Director of Nursing, Quality
Assurance investigative staff, and three direct care staff on administrative
leave following the comprehensive unclothed physical assessments. To
ensure a stable and consistent environment for residents, DHS assigned an
interim director who had experience in managing residential services. The
interim director was the former interim director at the Colorado Mental Health
Institute at Pueblo, also operated by DHS. She was assigned to PRC as of
April 22, 2015. Prior to this date, DHS was already in the recruitment process
to fill the director position as the previous director was set to retire April 30,
2015. DHS also assigned a team of veteran staff of qualified health care
professionals, including a physician, multiple nurses, a social worker who are
on site to provide increased oversight. Staff received training and support
regarding Abuse, Mistreatment, Neglect and Exploitation (MANE), Sexual
Abuse, and Rights of Persons Receiving Services. Additionally, DHS
management are providing increased on-site oversight at PRC.
The DHCPF coordinated with the Executive Director of the local case
management agency to ensure they were aware of the situation and would
provide oversight and support for PRC residents and their families. The
DHCPF approved temporary funding for the case management agency to hire
an additional staff person to assist with the transition of the responsibilities
related to review and follow-up of Critical Incident Reports and MANE
investigations. As these functions were previously overseen by PRC, the case
management agency experienced an increase in these duties, requiring
additional short-term funding, while a reorganization of the agency occurred.
The DHCPF provided technical assistance and training regarding MANE
investigations, Critical Incident Reporting, and Quality Assurance activities for
staff at the case management agency and the PRC to ensure staff providing

support, as well as those providing oversight, are knowledgeable of their

responsibilities and how to carry them out.
The DHCPF conducted a monitoring visit on April 22, 2015 after the initial
complaints were received. A follow up survey was conducted April 27, 2015
and April 28, 2015.
a. Where are they currently residing?
61 residents remain at PRC and one individual transitioned to another
HCBS provider.
H. What, if any, reviews/investigations are being undertaken at this
time and expected completion date, if known (e.g., currently under
investigation by the State agency, police investigation being
conducted)?
The DPHE conducted an investigative survey following receipt of the March
30, 2015 complaints. The survey exit conference occurred April 22, 2015 and
the certification deficiency report was sent to the facility on May 11, 2015. A
Plan of Correction (PoC) is required to be completed by DHS/PRC and will be
submitted to the DPHE. The original due date for the PoC to be submitted to
DPHE was May 26, 2015, however, DHS requested and was granted an
extension to June 9, 2015.
The DPHE received a response from DHS/PRC and DHS requested an
Informal Dispute Resolution (IDR). The IDR process consists of a desk review
and is an internal review that does not include an audience or public
attendance. With this request the case and facility arguments are reviewed by
an independent review process and the decision resulting from the review
process will be binding.
Law enforcement and Adult Protective Services were also notified of these
incidents and are conducting investigations as well. The Pueblo sheriffs office
investigated 19 complaints of abuse, maltreatment and unlawful sexual
contact. Six of these cases have been referred to the district attorney for
review and the sheriffs office is still investigating four cases. The DHCPF is
monitoring the progress of the investigations conducted by Adult Protective
Services in Pueblo.

I. Who at the State Medicaid Agency will take the lead on

communicating with CMS regarding this occurrence?
Barbara D. Ramsey, Deputy Director, Office of Community Living at the
Department of Health Care Policy and Financing will be the lead in
maintaining communication with the federal Centers for Medicare and
Medicaid Services (CMS).
J. Are other entities involved in the review/investigation? If yes, how
are their efforts being coordinated with the Medicaid Agency?
Yes, the other entities involved in the review/investigation aside from the
Department of Health Care Policy and Financing are, the Department of
Public Health and Environment, the Department of Human Services, the case
management agency, the Pueblo County Sheriffs Department, and Pueblo
County Adult Protective Services.
Viki Manley, Director, Office of Community Access and Independence at the
Department of Human Services, conducted a daily conference call with the
lead contact with DHCPF from April 24, 2015 through May 8, 2015 and
weekly conference calls thereafter. The DHS is communicating with the
Pueblo County Sheriffs Department and Pueblo County Adult Protective
Services regarding investigations and is providing this information to DHCPF.
Randy Kuykendall, Division Director, Health Facilities and Emergency Medical
Services Division at the Department of Public Health and Environment
conducts meetings with the DHCPF as needed.
The Case Management Agency and PRC are communicating with DHCPF
regarding case management needs and incident reporting policies. Staff with
the DHCPF conducted an in-person technical assistance meeting on May 28,
2015 and May 29, 2015 with the case management agency and PRC to
provide direction regarding the requirements for MANE investigations, Critical
Incident Reporting and Quality Assurance activities.

K. Was the allegation of abuse, neglect or exploitation reported per

State policy and procedures?

No, the allegations were not reported by the provider as required by state
regulation and policy and procedures. Pursuant to 10 CCR 2505-10, Section
8.608.6 C, allegations of abuse, mistreatment, neglect, and exploitation, and
injuries requiring emergency medical treatment or result in hospitalization or
death shall be immediately reported to the agency administrator or their
designee, and to the community centered board within 24 hours.
Furthermore, reports are required to be placed in the individuals record.
Pursuant to 10 CCR 2505-10, Section 8.608.8 B7 (2015), guardians must be
contacted within 24 hours regarding allegations of abuse. The investigation
by the DPHE indicates that the DHS did not report allegations of abuse
according to regulations or internal agency policy/procedure. According to
the investigation by the DPHE, guardians were not notified of the
comprehensive unclothed physical assessments prior to the site visit on March
25-26, 2015.
L. Did the harm to the individual(s) occur during the delivery of
services?
Yes, the inspections occurred while individuals were receiving either
residential or Day Habilitation services through the HCBS-DD waiver.
The impact to clients occurred during the implementation of comprehensive
unclothed physical assessments, which are outside the scope of services
provided in Residential or Day Habilitation services. The comprehensive
unclothed physical assessments were conducted by staff from the WRRC, a
state-operated ICF/IID facility, at the direction of the DHS, the state agency
legally responsible for the delivery of services at the both PRC and WRRC.
a. If so, who is the provider? (Both provider agency and
individual provider)?
The PRC is a state provider operated by DHS.
b. How long has the individual received services from this
provider?
The length of time varies for each individual. Please see Appendix 2 for
a complete listing of all individuals with their date of birth, date of
admission, and length of stay.

c. If a direct service worker caused the harm, did he/she have a

background check and current required training on file?
A direct service provider did not cause the harm.
d. Have there been prior allegations against the same provider?
Yes, PRC has had prior allegations of mistreatment, abuse, neglect,
and exploitation.
M. Please provide information about the total amount paid to the
provider for all of the services provided by the Pueblo Regional
Center. Please separately identify amounts paid for each HCBS
services and all non-HCBS.
Please see Appendix 3, for claims data for fiscal year(s) 2011, 2012, 2013,
2014, and 2015 (through April 30th).
N. Please clarify if the staff alleged to have been involved in the
incident(s) perform work or have performed work on behalf of the
States ICF/IDs. In addition, please clarify if the staff involved in
conducting the investigation or implementing remediation also
performs work on behalf of the ICF/IDs.
Yes, ICF/IIDs staff conducted comprehensive unclothed physical assessments
in the Group Homes and Day Habilitation program at PRC. No staff providing
services at the PRC perform work on behalf of the ICF/IIDs as the PRC is an
HCBS community waiver provider.
The staff conducting the investigation is the DPHE who does not perform
work on behalf of the ICF/IIDs. Implementation of Remediation will be
conducted by PRC which doesnt include staff who perform work on behalf of
the ICF/IIDs. However, oversight of the remediation occurs by the DRCO,
which also manages ICF/IIDs.

2. QUESTIONS RELATED TO THE STATE CRITICAL INCIDENT PROCESS:

A. What entity has the lead in coordinating the activities related to the
management of the critical incidents overall?
The Department of Health Care Policy and Financing (DHCPF) is the lead
agency responsible for oversight of Critical Incident Reports overall. However,
DHCPF contracts with the Department of Public Health and Environment
(DPHE) to review all Critical Incident Reports and requests that appropriate
follow-up by the case management agency be completed. The case
management agency then works with their case manager and the provider to
ensure follow-up is completed. The DPHE will coordinate and defer
investigations to law enforcement where indicated.
B. How does the lead agency coordinate the investigation with other
entities involved, if applicable?
Per the HCBS-DD waiver, service agencies are required to report specific
types of incidents to the case management agency immediately upon
detection but no more than 24 hours after the incident. These specific
incidents include, allegations of mistreatment, abuse, neglect, and
exploitation, medical crises requiring emergency treatment, death,
victimization as a result of serious crime, alleged perpetration of a serious
crime and missing persons. A written report must be submitted to the case
management agency within 24 hours.
The DHCPF operates a web-based critical incident reporting system and
requires all case management agencies to report Critical Incidents to the
DHCPF no later than noon of the next business day after discovering the
incident. The DPHE contracts with the DHCPF to review all Critical Incident
Reports entered into the web-based critical incident reporting system. Upon
review of the Critical Incident Report, DPHE requests appropriate follow-up
from the case management agency.
C. Under what circumstances does the State require the completion of
an incident report? Was an incident report submitted for this
occurrence?
Pursuant to 10 CCR 2505-10, Section 8.608.6 (2015), Incident Reporting
requires, case management agencies and Regional Centers to have written
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policies and procedures regarding timely reporting and reviewing of incidents

which include:

Injury to person receiving services;

Lost or missing persons receiving services
Medical emergencies involving persons receiving services
Hospitalization of persons receiving services
Death of persons receiving services
Errors in medication administration
Incidents or reports of actions by persons receiving services that
are unusual and require review
Allegations of abuse, mistreatment, neglect, or exploitation
Use of safety control procedures
Use of emergency control procedures
Stolen personal property belonging to a person receiving services

No incident report was submitted to DPHE regarding the comprehensive

unclothed physical assessments.
D. Is there a specific timeframe within which Critical Incident Reports
(CIRs) must be completed? If a report was submitted for this
incident, was it on time?
Pursuant to 10 CCR 2505-10, Section 8.608.6 (2015), Incident Reports must
be submitted to the case management agency within 24 hours. However, in
this case, the case management agency was not notified of the
comprehensive unclothed physical assessments via the completion of an
Incident Report. Consequently, the case management agency did not submit
a corresponding Critical Incident Report.
E. Is there a required timeframe to remove individual(s) from
imminent risk of harm?
Pursuant to 10 CCR 2505-10, Section 8.608.8 B8 (2015), case management
agencies, service agencies, and Regional Centers must ensure prompt action
to protect the safety of individuals receiving services if determined necessary
and appropriate. These actions may include removing the person from
his/her residential setting. There is no specific timeframe within which to
remove individuals from imminent risk of harm.

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a. If yes, were the individuals removed according to the

timeframe?
The investigation conducted by DPHE did not indicate that any of the
individuals involved in the comprehensive unclothed physical
assessments by WRRC staff are in imminent danger and no residents
were removed from the ten Group Homes.
F. What is the process and timeframe for the provider to notify
parents/guardians/legally responsible individual(s) regarding the
incident? Was the process/timeframe followed in this instance?
Pursuant to 10 CCR 2505-10, Section 8.608.8 (2015), mistreatment, abuse,
neglect, or exploitation (MANE) is required to be reported to a parent of a
minor, guardian, authorized representative, and CMA within 24 hours.
Additionally, Pueblo Regional Center (PRC) Policy, 1.4.A2, requires that the
Emergency On-Call staff person who is notified of the incident notify the
guardian or authorized representative immediately.
The Department of Human Services (DHS) notified families and guardians of
the comprehensive unclothed physical assessments on April 2, 2015 via a
letter and did not meet the reporting requirement. The DHS is required to
notify families within 24 hours of the incident occurring.
G. What confidentiality requirements are in place to protect the
victim(s) particularly where the media is involved? Were the
requirements followed in this instance?
Yes, confidentiality requirements were followed. Please see Appendix 4 for
PRCs policies addressing confidentiality and management of records. All
policies were followed on March 25 and March 26, 2015 and no resident
records were shared with any outside entities.
The DHCPF operates with strict confidentiality requirements for all
communications as stated in Section 25.5-10-226, Colorado Revised Statutes
(CRS), however, there are no specific requirements regarding media
involvement. The CRS states that a record for each person receiving services
shall be maintained by the Community Centered Board and that this record is
not public and that the records are subject to evidentiary privileges
established by law. Furthermore, disclosure of the information and records is
permitted only to: The person receiving services, parents of a minor child,
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legal guardian, to anyone authorized by one of the previously named

persons; in communication between qualified professionals; to the extent
necessary to make claims for aid, insurance, or medical assistance; for the
purposes of evaluation, gathering statistics, or research when no identifying
information is disclosed; to the court when necessary; to persons authorized
by an order of the court; and to the agency designated as the protection and
advocacy system for Colorado when certain criteria are met.
H. Are there any specific requirements for incident reporting and
investigation based upon age (e.g., at risk adult or older adults
reporting the Adult Protection)? If they apply here, were the
requirements followed?
There is no specified age requirement for Critical Incident Reports. However,
allegations of abuse, neglect or exploitation of adults 70 years of age or older
must be reported to law enforcement as stated in Section, 18-6.5-108,
Colorado Revised Statutes.
Person specific Protected Health Information (PHI) redacted. The DHS did not
notify law enforcement regarding the comprehensive unclothed physical
assessments conducted on March 25 and March 26, 2015.
I. Who is responsible for ensuring remediation/corrective actions are
completed?
The DPHE inspects PRC pursuant to the Interagency Agreement with the
DHCPF and is responsible for citing any deficient practice, reviewing the
facilitys Plan of Correction (PoC), and making any recommendations to the
DHCPF regarding certification. When the PoC is submitted, the DPHE will
review and consider the PoC and the provider will implement the terms of the
PoC. If approved, the DPHE will conduct a follow-up survey to verify
compliance with the PoC. However, the DHS did not submit a PoC and
instead requested an Informal Dispute Resolution, the results of which are
pending.

a. How was remediation handled for this incident?

The DPHE issued Deficiency List(s) to the certified Group Homes and
the Day Habilitation program. Please see Appendix 5 for a copy of the
Deficiency List. The DHS requested a two week extension to provide
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the Plan of Correction (PoC) to DPHE, which was due June 9, 2015.
The process to identify deficiencies is still in progress. The DPHE
received a request for an Informal Dispute Resolution on June 10,
2015, and the result of that review is pending. However, many
activities needed for overall remediation are apparent.
The PRC is responsible for implementation of remediation under the
management of the Division of Regional Center Operations (DRCO) at
the DHS. The case management agency is responsible for ensuring
the health and safety of residents of PRC through monitoring of the
Service Plan. The case management agency ensures services are
provided according to those authorized in the Service Plan and that
services are revised as necessary, to ensure the health and safety of
individuals. This can include increasing the frequency and/or duration
of specific services, adding services, decreasing services, and changing
providers. The DHCPF is responsible for the oversight of PRCs
effective implementation of HCBS-DD waiver services. The DHCPF has
completed an on-site technical assistance training and will continue to
provide on-site and over the phone technical assistance as needed.
The DHS is responsible for staff remediation and ensuring ongoing
regulatory compliance in operating PRC. At PRC, DHS:

Has strengthened requirements for investigating and reporting

to Adult Protective Services and law enforcement (including
more thorough investigation of incidents by both Adult
Protective Services and law enforcement). As of March 31,
2015, all employees were required to review policies regarding
Mistreatment, Abuse, Neglect and Exploitation (MANE), as well
as sign-off that policies had been reviewed. Employees also
reviewed a PowerPoint presentation regarding MANE.
Employees were also required to review policies related to rights
of persons receiving services.
Provided additional training to PRC staff, including
Cardiopulmonary Resuscitation (CPR), staff supervision and
progressive discipline; reviewing nursing practices and
implementing new processes to improve the quality of resident
care. Please see Appendix 6 for list of trainings beginning in
May 2015.
Is evaluating long-term organizational structure solutions,
including separating the Regional Center quality assurance
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function from the chain of command within the Regional

Centers, reviewing the structure of direct care staff chain of
command and alignment with nursing oversight, and
broadening the authority within PRC for progressive discipline of
staff.
b. Has the incident been referred to law enforcement?
No, the incident was not referred to law enforcement. Law
enforcement was notified regarding incidents identified during the
comprehensive unclothed physical assessments. Pueblo sheriffs office
received 19 incidents for investigation, four of which are pending, and
six have been sent to the district attorney for review.
J. What entity is responsible for analyzing incidents to identify trends
and make recommendations to revise procedures to better address
identified risks to health, safety, and welfare?
The DRCO collects Incident Report data monthly from all three regional
centers. As part of that data collection, DRCO also requires regional centers
to review each instance of physical intervention and identify root causes,
possible training needs, and/or the necessity of individual treatment plan
revisions. In addition, PRCs Quality Assurance Performance Improvement
(QAPI) process requires that all Incident Reports be reviewed by the QAPI
Incident Report Review Subcommittee at least monthly. The policy and
procedure, which was updated on June 4, 2015, requires that all
interventions are followed by reassessment or re-measurement to evaluate
the effectiveness of the intervention. Trends are identified and analyzed to
determine their significance. Causal links between the interventions and the
results that are observed are examined. Interventions that influenced the
outcome, with differentiation of those that were most influential, are
identified, including any intervening or confounding factors that may have
contributed to any changes that have occurred.
The case management agency is required to analyze and identify trends of
Critical Incident Reports for all providers serving participants enrolled with
them, including those submitted by PRC, and providing the analysis of trends
to the DHCPF on a quarterly basis. The DHCPF is responsible for revising
procedures statewide.

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a. How is the State able to identify potential trends related to

critical incidents (e.g., by provider, statewide)?
Per the HCBS-DD waiver, case management agencies are required to
analyze Critical Incident Report data and submit quarterly reports to
the DHCPF, which include trends related to providers, type of Critical
Incident Reports, and staff involvement.
b. Has the State identified any trends related to this incident?
No trend could be identified because the Critical Incident Reports from
PRC were not included in the aggregated data received in the quarterly
reports from Colorado Bluesky Enterprises. The DHCPF identified the
absence of the PRC data from the reports as an outcome of the
current incident.
c. Have any system improvement strategies been developed as
they relate to this incident?
This incident illuminated the need for system wide analysis of current
practices for critical incident reporting to determine how those
practices protect the health and welfare of participants, align with
regulation and support waiver assurances. That analysis will include a
review of how the various agencies charged with protecting vulnerable
individuals are coordinating efforts. Once the analysis is completed,
system improvement strategies will be developed.

3. QUESTIONS RELATED TO SERVICE PLANNING, IMPLEMENTATION AND

MONITORING?
A. Do the participants involved in the occurrence have specific serious
risk issues (e.g., special diets, serious illnesses, and serious mobility
issues)? If yes:
Yes, most individuals residing at Pueblo Regional Center (PRC) have specific
and serious risk issues.

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a. Is there a protocol in the Service Plan to mitigate risks?

Each individual has a Service Plan that identifies the services needed
by the individual according to the individuals assessment and the
interview conducted between the individual, the individuals family or
guardian and the case manager. The needs assessment includes any
information about the individuals exceptional medical and behavioral
needs, but does not include the specific risk issues mentioned above.
However, each individual is required to have a plan of care with his or
her provider, which is kept up to date and documents how risks for
that individual are mitigated. Direct care staff are required to be
familiar with each individuals plan of care and to provide services in
accordance with that plan.

b. Was the protocol followed?

No. The protocols within the plan of care were not followed. In some
cases, the Department of Human Services (DHS) investigation
determined that the plan of care was not sufficient, or was not carried
out or that staff were not fully trained to carry out the plan.
c. Was staff properly trained regarding the participants specific
needs and risks?
In some cases, the DHS investigation determined that staff were not
fully trained to carry out the plan.
B. When were individuals Service Plans last updated (please specify
for each individual involved)?
Please see Appendix 7 for a complete list of Service Plan updates for
individuals at PRC.
a. Was it updated timely and appropriately?
Review of the Service Plans for all 62 residents at PRC during the time
of the incident, showed that 97% were updated timely and
appropriately.

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C. Was the Case Manager monitoring implementation of the plan as

required? Did the case manager identify any problems? If yes,
what happened?
No, case managers did not monitor implementation of the Service Plan as
required. Per the HCBS-DD waiver, case managers are required to visit each
provider site at least once per year and to complete face-to-face monitoring
with each participant at least once per quarter. In review of the
documentation in the Benefits Utilization System (BUS) for all 62 residents of
PRC, 29% of the quarterly contacts were completed timely.
Of the 62 residents, 47% of them had a problem or incident identified during
the Service Plan year. Of those, 6.7% were followed-up by the case manager
to ensure satisfactory resolution.
a. How are case management entities/agencies assessed to
ensure they are fulfilling contractual obligations?
Annually, case management agencies are assessed through the Quality
Improvement Strategies (QIS).
Performance measures relative to the case management agencies
contractual obligations are included in the following waiver assurances:
Administrative Authority
Level of Care
Service Plan
If deficiencies are identified, the case management agencies are
required to complete individual case remediation. The Department of
Health Care Policy and Financing (DHCPF) receives and reviews all the
raw QIS data from each case management agency. A deficiency list is
then provided to the case management agency to make corrections to
individual cases. The case management agencies are given 30-45 days
to make identify corrections at which time they update the DHCPF on
how the corrections were made. Remediation may also include the
case management agency training staff on identified issues.
Please see Appendix 8 for the most recent QIS and remediation
information related to Colorado Bluesky Enterprises.

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D. Did the participant recently transition from an institution?

In the last two years, three individuals transitioned from a criminal justice
institution. No other participants transitioned from an institution in the last
two years.
a. Does the State have a process to conduct periodic transition
monitoring reviews? If yes, did the review happen and what
was found?
The State participates in Money Follows the Person, which requires
periodic transition reviews and a Quality of Life Survey. However, PRC
provides Residential Habilitation in group homes, which are not eligible
for Money Follows the Person transitions.
Case managers support individuals to transition to the community and
all individuals who transition from an institution to community services
through the HCBS-DD waiver receive quarterly face-to-face monitoring.
However, there is no monitoring specific to transition and none
occurred for the three individuals who transitioned to PRC from
corrections.
b. Are Money Follows the Person individuals involved?
No, PRC provides Residential Habilitation in group homes, which are
not eligible for Money Follows the Person transitions.
E. If the individual was not living at home, was the family/guardian
notified? Was the notification made in accordance with the States
current policies and procedures? If notification was completed,
please describe how and when the notification occurred.
No, all individuals were living in Group Homes at PRC and the
families/guardians were not notified of the incident within the required
timeframe. The States current policies and procedures require that the family
and guardian are notified within 24 hours. Parents and guardians were
notified via a letter dated April 2, 2015. Please refer to Appendix 1 for a copy
of the letter.

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4. QUESTIONS RELATED TO HEALTH AND WELFARE OCCURRENCES IN A

RESIDENTIAL SETTING?
A. How long has the individual(s) been residing in this location?
There were 62 individuals living at Pueblo Regional Center (PRC) at the time
of the investigation. These individuals lived at PRC from three months to
almost 48 years. Please see Appendix 2 for a complete listing.
a. How many individuals were impacted?
All 62 individuals receiving services from PRC were impacted.
i.

Where is the individual(s) physically located now?

All individuals with the exception of one, who has transferred to
a host home, continue to live in their homes with the PRC.

ii.

What is the individuals current health status?

There have not been any unusual or remarkable medical or
health symptoms or issues reported as a result of the physical
assessments conducted March 25 and March 26, 2015.
Person specific Protected Health Information (PHI) redacted.

iii.

Is he/she/they free from imminent risk of harm? Is the

individuals health and welfare now safeguarded (and
others if the incident involved a direct service worker)?
Yes, individuals are free from imminent risk of harm. The
individuals are receiving services in a stable environment from a
qualified provider with case management services in place to
ensure the health, safety and well-being of the individuals
impacted.

B. Have other critical or major and unusual incidents been reported by

or on behalf of individuals residing at this location or other locations
served by this provider? If yes:

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Yes, the site visit and comprehensive unclothed physical assessments

conducted on March 25, 2015 and March 26, 2015 found ten reportable
incidents. The incidents were investigated by the DPHE and unsubstantiated.
a. What types of incidents have been reported?
The ten reportable incidents include:

No positioning plan for resident on Hospice Care

Verbal abuse
Unexplained cuts
Verbal abuse/teasing about incontinence
Sexual assault
Violation of privacy/visual stalking
Verbal abuse/teasing
Verbal abuse/harassment
Neglect
Manipulation/verbal abuse

b. If the incident involved a direct service worker to the

individual, has the abuser/alleged abuser been removed from
the setting (e.g., temporary suspension)?
In April 2015, the Director, Assistant Director, Director of Nursing,
Quality Assurance investigative staff, and three direct care staff were
put on administrative leave pending the outcome of investigations
following the 10 incidents identified during the site visit in March 2015.

c. Have there been prior allegations/incidents reports against

this provider and/or direct services worker?
Yes, in November 2014 residents of PRC had cuts which appeared to
form words in their arms. An investigation was completed by the PRC
Quality Assurance staff resulting in the termination of two employees
and Disciplinary and Corrective Action of another employee. The
sheriffs office also completed an investigation, however, no charges
were filed.
From January 2013 to March 2015 a total of 63 incidents were
documented and investigated internally by PRC. Please see Appendix 9
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for summary information regarding the type of incident, who was

involved, and if the abuse, neglect, and/or exploitation were
substantiated. Remediation for these incidents varied, based on the
outcome. In some instances staff were terminated, others were
retrained or provided additional supervision, staff were also reassigned
to different individuals with different disabilities, and an increase in
supervision of individuals also occurred.
Additionally, the Department of Public Health and Environment (DPHE)
conducted a survey from April 19-23, 2010 in which problems were
identified. PRC provided a Plan of Correction which was accepted by
DPHE and monitored for adherence.
C. What entity is responsible for the first-line oversight of this waiver
home?
The Department of Health Care Policy and Financing (DHCPF) designates
DPHE to conduct certification surveys and make certification
recommendations per an Interagency Agreement.
Have there been any licensing/certification and/or code violations
cited?
Yes. Upon completion of a survey in 2010, several deficiencies were
identified. Most deficiencies related to improper documentation in the Service
Plan, Individualized Services and Supports Plan, as well as due process when
rights are suspended. Please see Appendix 10 for a list of occurrences.

a. When was the last time this provider was monitored?

The DPHE conducts both licensing and certification surveys for the
PRC. The PRCs licensure surveys for the ten individual Group Homes
were completed in February 2013 and April 2014. Certain standards,
or low-level deficiencies, were cited at the time of these surveys;
however, no pervasive concerns were found. All deficiencies cited in
relation to certification and licensure were corrected timely.
D. When was the last face-to-face case management visit for waiver
participants residing at this location? Were any issues noted at that
time and in other prior visits?
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Please see Appendix 7 for a complete list of the most recent face-to-face case
management visits for each resident of PRC. Appendix 11 includes summary
data of timeliness regarding Service Plan updates, required face-to-face
contacts, and whether issues were noted during the Service Plan year. Of the
62 individuals at PRC, 34% had their required face-to-face monitoring
conducted in a timely manner. Of those 62, 47% had an identified incident or
concern during their Service Plan year.
5. QUESTIONS RELATED TO PROVIDER QUALIFICATIONS
A. What process is in place to monitor the provider involved in the
occurrence to ensure it meets qualification requirements as
specified under the approved waiver?
The Department of Public Health and Environment (DPHE) conducts onsite
surveys prior to initial certification and licensure, and then conducts ongoing
surveys on a three year cycle. The DPHE also investigates any complaints
received regarding Pueblo Regional Center (PRC), and oversees occurrence
reports made by PRC to the DPHE. For this investigation, the DPHE is
conducting ongoing monitoring and will perform an onsite revisit to ensure
adherence to the regulations and provider qualifications, pending the
outcome of the Informal Dispute Resolution.
B. Were the provider qualifications in the approved waiver met?
Yes, the provider is licensed according to qualifications specified in the
waiver.
C. What training is required for the provider/staff rendering services
for individuals at this location/served by this provider?
Pursuant to 10 CCR 2505-10 Section, 8.603.9 D (2015), the provider is
required to have an organized program of orientation and training of
sufficient scope for employees to carry out their duties appropriately. This
program of orientation must provide:

Extent and type of training to be provided prior to employees or

contractors providing supports and services having unsupervised
contact with persons receiving services

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Training related to health, safety and services and supports to be

provided within the first 90 days for employees and contractors
Training specific to the individual(s) for whom employees or
contractors will be providing services and supports

In addition to the Department of Health Care Policy and Financings (DHCPF)

certification and HCBS waiver requirements for staff training, the following
DPHE regulations address Training for Licensed Residential Group Homes
pursuant to 6 CCR 1011-8, Section 7. Training includes:
policies and procedures regarding initial orientation and ongoing
trainings,
training specific to residents needs prior to working unsupervised with
a resident,
training regarding resident rights, and within the first 30 days
training must be completed regarding reporting abuse, neglect,
mistreatment and exploitation.
The provider must document all staff trainings and document orientation and
training in emergency procedures for each new staff member and newly
admitted resident capable of self-preservation.
D. When were provider qualifications and training requirements last
verified for waiver providers rendering services to individuals
residing at this location/served by this provider?
Provider qualifications and training requirements were last verified at the time
of the last surveys for certification in June 2012 and licensure in February
2013 and April 2014.

E. Are background checks required?

a. If so, were they on file for the provider(s) involved (if
applicable)?
Per the HCBS-DD waiver, background checks are required and were in
place at the time of the last survey.
F. Are providers verified against State or national registry of excluded
providers?

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The DHCPFs fiscal agent for its Medicaid Management Information System is
Xerox State Healthcare. Xerox State Healthcare checks the federal
Department of Health and Human Services Office of Inspector Generals List
of Excluded Providers (LEIE) at the time of enrollment. At the time of
enrollment, Xerox State Healthcare also checks the Centers for Medicare and
Medicaid Services (CMS) National Plan and Provider Enumeration System
(NPPES) website for National Provider Identification verification. DHCPFs
Program Integrity unit conducts a monthly check of existing Medicaid
providers against the LEIE, the System for Award Management (SAM), CMS
Medicare Exclusion Database (MED) and CMS State Medicaid Terminated
Provider List. Pursuant to 10 CCR 2505-10, Section 8.130.35, each provider is
required to screen prospective employees and newly signed contractors
against the LEIE prior to hiring and on an ongoing basis monthly.
G. How are providers monitored initially and on an ongoing basis?
Per the HCBS-DD waiver, providers are surveyed initially at the time of
enrollment and then every three years thereafter. Additional monitoring may
occur upon the receipt of complaints or Critical Incident Reports.
H. What process is in place to maintain appropriate staffing levels
when staff is unable to report to work? Was it followed in this
instance?
The PRC has an available staffing pool of 37 people to fill daily vacancies in
addition to continuous hiring for both nursing and direct care staff as
positions become vacant. There are three staffing/scheduling supervisors on
duty in the staffing office from 9:00 a.m. to 7:00 p.m. seven days a week.
Two staffing office personnel are on duty and take calls from 9:00 p.m. to
7:00 a.m. seven days a week. The staffing/scheduling office personnel are
responsible to assure group homes have adequate staff-to-resident ratios.
One staff carries a cell phone after hours. Schedulers have a master schedule
with minimum ratios determined. Direct care staff in the group homes are
required to call off sick with two hour notice, and the schedulers cover the
shortage by use of PRC Staffing Pool. PRC staff must remain on duty until
relieved by the next shift, which may necessitate a double shift. Double shifts
can be covered on a voluntary basis, however, staff covering must carry the
required licensure.
I. Will a relocation of impacted individuals be necessary?

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A relocation of impacted individuals is not necessary.

J. How will the State engage family members or other representatives
in decision-making should a transition/relocation of impacted
individuals be required?
If a transition/relocation of impacted individuals is required, the DHCPF will
ensure that case managers with the case management agency conduct
Service Plan meetings with family members, guardians and other
representatives to assist with making decisions regarding a change in
provider and services to meet the needs of all residents.
K. Has the State placed this provider under a corrective action plan or
has additional monitoring occurred as a result of this allegation?
The DPHE completed their investigation and provided a list of deficiencies to
the Department of Human Services (DHS)/PRC. The DHS submitted a request
for an Informal Dispute Resolution and the outcome is pending. The case
management agency is monitoring service delivery on an individual client
basis.
Additionally, the DHCPF has increased monitoring of oversight of both PRC
and the case management agency. Please refer to Question 6.B and 6.C for
current and future monitoring activities.

L. Has the State terminated or initiated provider termination

procedures for all provider numbers held by the provider at issue?
If not, does the State intend to terminate this provider and when?
The DHCPF has not terminated or initiated provider termination procedures
for PRC. Any termination decisions are pending the outcome of the survey
conducted by DPHE and the outcome of the Informal Dispute Resolution
process.
M. Has the provider been added to the State and/or national registry of
excluded providers?

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The provider has not been added to the State list of terminated Medicaid
providers or a national registry of excluded providers.
6. QUESTIONS RELATED TO ADMINISTRATIVE AUTHORITY
A. Please provide copies of the Interagency Agreement between the
State Medicaid Agency and the Department of Public Health and
Environment and the Provider Agreement between the State
Medicaid Agency and the Pueblo Regional Center.
Please see Appendix 12 for the above referenced documents.
B. Has the State delegated investigation of the allegation(s) to another
agency? If so, please describe how the State Medicaid Agency is
overseeing the resolution of this incident?
Yes, the Department of Health Care Policy and Financing (DHCPF) has
delegated investigation of the allegations to its contracted entity, the
Department of Public Health and Environment (DPHE). The DHCPF is the
lead agency in overseeing the resolution of this incident by providing on-site
oversight and technical assistance to Pueblo Regional Center (PRC) and the
case management agency to ensure safeguarding processes are followed.
On May 28, 2015 and May 29, 2015, DHCPF staff met with staff from PRC
and Colorado Bluesky Enterprises (CBE), the case management agency. Each
meeting consisted of a review of current processes related to Critical Incident
Reports, MANE investigations, and Human Rights Committee. The DHCPF
staff met with each agency separately on May 28, 2015 in the morning, then
held a joint meeting the afternoon of May 28th. At this meeting staff from PRC
and CBE developed a plan to transition Critical Incident Reports, MANE
investigations, and Human Rights Committee from PRC to CBE. They
developed this plan with support from DHCPF staff.
The DHCPF staff provided onsite monitoring again on June 16, 2015 and June
17, 2015. This meeting consisted of meeting with PRC staff to review staff
schedules and visit each group home. The DHCPF staff conducted this visit to
ensure adequate and proper staffing of each group home.
Please see Appendix 14 for meeting agendas and summaries.

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C. What systemic changes will the State implement to prevent the

recurrence and mitigate future risks?
The DHCPF will update regulations regarding MANE investigations and
reporting, Critical Incident Reports, and Human Rights Committee, to make
the distinction between HCBS and ICF/IID services delivered through
Regional Center providers. Additionally, the Department will update
regulations regarding case management and the requirements for monitoring.
The Department will conduct monitoring of case management agencies which
will include desk reviews and onsite visits. The review will consist of ensuring
the timeliness of monitoring and Service Plan development as well as the
quality of monitoring and Service Plan development.
Additionally, the DHCPF will use data based outcomes to ensure quality case
management is received by individuals in services. The Department has
already created a training curriculum for case managers and will begin the
development of the training materials for this.
Upon implementation of the above, the DHCPF will conduct trend analysis of
the information, which will lead to a revision of policies, procedures, and
training.
7. QUESTIONS RELATED TO TRANSITION PLAN AND HCBS SETTINGS
REGULATIONS
A. When the State preliminarily assessed the settings in which people
live and receive their services in the HCBS waiver for Persons with
Developmental Disabilities regarding the Statewide Transition Plan,
did the State make a determination about whether or not this
setting was in full, partial, or overall non-compliance? Please
explain the States preliminary findings for all of the settings in
which people at Pueblo Regional Center live and receive their
waiver services?
The Department of Health Care Policy and Financing (DHCPF) administered
two self-assessment surveys for all Home and Community Based waiver
approved service providers state-wide, including Pueblo Regional Center
(PRC). The data is still being finalized, however the preliminary data shows
that PRC is in partial compliance but will need to address some areas in which
they are non-compliant with the new HCBS Settings Rules. In the first
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provider survey, the data collected from PRC indicates that resident choice
and access to the greater community needs to be addressed including;
clients choice of employment, choice of when and where client can be in the
community, choice of house mates and access to food of the clients
choosing. The data collected this far shows that the Regional Centers have
many services that would lend them to come into compliance. One example
is that all of the Group Homes at PRC are located in residential neighborhoods
and not on a state run campus.
The DHCPF is working on the analysis of the data collected in the Secondary
Provider Survey to better understand where the PRC is in comparison to the
new Settings Rule. The transition plan includes PRC in the first wave of onsite reviews to better support them during this process. This first wave of onsite reviews will take place between December 2015 and May 2016.
8. QUESTIONS RELATED TO ON-GOING OR OUTSTANDING ISSUES?
A. Is there is any supporting documentation for any of the information
the State provides in response to these questions, please provide a
copy of the documentation to CMS with the States responses.
Yes. The Department of Health Care Policy and Financing (DHCPF) has
included appendices to provide supporting documentation of questions
answered.
B. Is there a review/investigation (formal or otherwise) pending or
completed regarding this matter?
The Department of Public Health and Environment (DPHE) conducted the exit
survey for Pueblo Regional Center (PRC) on April 27, 2015 and April 28, 2015.
The Department of Human Services (DHS) submitted a request for an
Informal Dispute Resolution to the DPHE on June 10, 2015. The
investigations of the allegations identified during the comprehensive
unclothed physical assessments are completed and all allegations have been
unsubstantiated.
C. If the review/investigation is not complete, when does the State
estimate completion?

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The DPHE completed an investigation and provided the report to DHS/PRC on

May 11, 2015. The DHS/PRC requested an Informal Dispute Resolution, the
results of which are pending.

29