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 Environments (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 CDPHEs 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 centers staff. As
part of the review, the CDHS team conducted physical wellness checks on most of the centers
residents.
Following a complaint about the Pueblo Regional Center, we conducted a thorough investigation of
the Centers 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 Sheriffs 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
PRCs 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 CDPHEs 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
Youll find that the CDPHE report and CDHS Plan of Correction are the same for each address. The
Direct Service PRC, is slightly different.