Abuse report sparks reform
Monitor will ensure state is fixing the Pueblo center for developmentally disabled.
An independent monitor will make sure the state is fixing issues at a troubled center in Pueblo where federal officials have found systemic abuse of individuals with severe intellectual disabilities.
Gov. John Hickenlooper said the monitor will be in place within the next few weeks to “ensure that the reforms we are doing are up to best practices.” Federal officials requested the monitor in an August report, but the state already had plans to hire one, among making other reforms, he said.
“The well-being of residents entrusted in our care remains our priority,” he said. When state officials learned of the 20142015 abuses, “it was beyond disturbing,” Hickenlooper said in an interview with The Denver Post. “Everyone in this office was upset. We acted swiftly. Fired people. Brought in new people,” and notified local law enforcement and federal authorities.
State Medicaid officials say they still are working on coming up with a streamlined approach for identifying and preventing abuse, neglect and exploitation of those living in the Pueblo Regional Center and similar facilities. More than a year and a half has passed since allegations of physical and sexual abuse prompted state officials to conduct “body audits” on 62 residents at the Pueblo center.
The state will not finish overhauling systems that alert the state of occurrences and critical incidents at centers for individuals with developmental disabilities until September 2017, according to a corrective plan the state filed with a federal agency this week.
The Colorado Department of Health Care Financing and Policy “has processes underway to identify the multiple cross
“As parents and guardians, we don’t have a clue what is going on and who is telling the truth.”
system issues in order to develop a plan,” they said in the plan. Work on fixing the issue is still “in process,” the document states.
Fixing state monitoring of critical incidents and occurrences at the center is crucial, according to a blistering report from federal officials who were so concerned they enacted a moratorium on new residents at the Pueblo Regional Center and ordered Colorado to repay millions of dollars in Medicaid funding.
Hickenlooper said he expects Colorado will have a robust system to monitor and prevent abuses in place well before September 2017, the target date listed by state officials in their response to the federal request for action. And the governor said he will continue discussions with state human services director Reggie Bicha and other officials to improve the entire system that serves Coloradans with disabilities, including the 20 community-centered boards that manage Medicaid funds for the disabled and link them to homes and services.
“This whole process of evaluating our systems doesn’t just stop at the boundary of the Pueblo Regional Center,” he said.
As for how much money Colorado will have to return to the federal government, Hickenlooper said that remains under negotiation.
The federal report blasted state oversight, saying state officials did not properly investigate allegations at the Pueblo center despite “numerous severe incidents reported,” and that the center “has a history of not properly reporting or responding to incidents.”
Reports of abuse
Federal investigators found residents at the center had been repeatedly abused. A group of men, some nonverbal, had violent words etched into their skin by staffers, who told investigators the etchings were the result of “paranormal activity.” Another staffer physically abused and threatened residents and threatened to slash the throat of another resident. One employee there extorted a sexual act from a resident in exchange for a soda. At least three residents have died, two due to bowel obstructions and a third after a collapse. An intoxicated staffer drove another resident to a doctor’s appointment.
Federal investigators reviewed how officials responded to abuse that occurred before November 2015 and substantiated many of the allegations. Also, their on-site review in April “revealed that a number of serious incidents have continued to occur.”
The Pueblo Sheriff’s Office said it had had investigated 19 claims about staffers at the Pueblo center and had referred eight cases to the District Attorney’s Office in Pueblo for prosecution. Officials with the District Attorney’s Office did not return numerous telephone calls seeking clarification on the status of those criminal cases.
While the state’s corrective plan said state Medicaid officials still are trying to determine the best way to track critical incidents and occurrences at the Pueblo center and similar facilities, that plan stressed that the state is making strides elsewhere to ensure residents are safe. The Colorado Department of Human Services has put in place a new reporting system that automatically notifies that agency’s executive management up to and including Bicha of serious incidents, according to the corrective plan.
The human services department is responsible for overseeing the daily operations at the center. The Colorado Department of Health Care Policy and Financing also plays a role since it is the state’s ultimate manager of Medicaid funds that finance the housing of residents at the center. As fiscal agent, HCPF is in charge of ensuring the state is providing proper oversight of the daily operations. A third state agency, the health department, is in charge of licensing the center. The corrective plan noted that an employee with the state’s Medicaid agency now is housed with the health department to provide coordination and to provide “follow up, resolution and trend analysis.”
State Medicaid officials also have boosted training of case managers to make sure they are now doing a better job of tracking abuse allegations. And a new position in HCPF has been created to review the abuse tracking by those case managers.
Overhauling process
“There now are two other sets of eyes consistently on that reporting process that weren’t there before,” said Barbara Ramsey, the HCPF’s director of intellectual and developmental disabilities. “What we’re working on now is to actually change the reporting systems so we have one streamlined, consistent process that goes into one system.”
Parents and guardians of people who live at the Pueblo center were outraged and frightened by the new abuse details that became public this week. They were aware of reports more than a year ago about residents with words scratched into their skin, but not the sexual assault or a resident burned with a hair dryer, among other allegations, said Jim Malila, whose son lives at the center.
“As parents and guardians, we don’t have a clue what is going on and who is telling the truth,” he said. “It’s really a great concern to us.”
Parents and guardians want to know exactly when each of the abuses occurred and how they were reported to law enforcement, and local and state agencies. They also want answers about why it has taken more than a year to address staffing issues at the Pueblo center, where they say caregivers are overworked. Staff turnover is about 40 percent. Bicha said he intends to add 20 more people and increase salaries.
Malila said staff members have twice saved his son’s life and he has nothing but “glowing recommendations” regarding his son’s caregivers. The staffing shortages have been “extremely hard on them,” he said. “We’re pleased that finally the staff will get some relief.”
The corrective plan the state filed with the federal Centers for Medicare & Medicaid Services also acknowledged deficiencies in case management of residents.
Case managers, provided by the community-centered board Colorado Bluesky Enterprises, were supposed to have face-toface meeting with each resident at the Pueblo center every three months. But records show that those face-to-face meetings were completed only 29 percent of the time. Further, of the 62 residents, nearly half reported problems the case managers were supposed to address. But case managers provided follow-up on those problems to ensure satisfactory resolution in only 7 percent of those cases, records show.
The state did not do an on-site performance review of BlueSky to address problems in case management until late August, according to the state’s corrective plan. That on-site review occurred days after federal officials sent their critical report.
The corrective plan shows the department of human services is only now beginning to grapple with severe staffing issues at the regional center in Pueblo.
That agency still has not ensured accurate tracking and monitoring of staff turnover at the center, has yet to conduct exit interview with staff members who are leaving and has not evaluated employee compensation competitiveness, according to the state’s plan.
The plan shows hiring for the 20 new full-time positions is not expected to be completed until June 2017. Even as the state works to create more positions at the troubled center, staff vacancies in current positions are putting the care of residents in peril, records show. The state said in the report that it is still struggling to fill 19 current direct care vacancies and has not yet begun accurately monitoring vacancies at the regional center in Pueblo or two other similar centers in Wheat Ridge and Grand Junction.