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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.
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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:
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ii.
iii.
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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:
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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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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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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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