Sunday, October 30, 2016

Lack of Staff at Wyoming Life Resource Center a Grave Concern

WLRC Staffing

            A 2013 Wyoming Department of Health (WDH) Study identified staffing ratios as a significant factor in the annual cost per client.” This analysis identified potential for substantial savings from reduction in staff ratio.”  This report goes on to say that the staff to client ratio at Wyoming Life Resource Center (WLRC) is above the national average, above the ratio prescribed by federal regulations, and that the ratios were in accordance to a settlement which is no longer enforceable,
            In response to legislative demands to make the center more efficient, the Department of Health chose to reduce the operating budget of the WLRC through attrition. (As staff resigned or retired, positions were purposefully left vacant.)  In order to achieve this, residents were moved around to reduce the number of cottages being staffed.  As a result, residents were forced to live in overcrowded and cluttered homes, give up personal belongings and other items which made their living quarters more “home-like," and lost the ability to participate in activities simply because there were not enough staff to afford the opportunity. In some cases, residents were unable to attend day programming or therapies because there was not enough staff to transport them. These changes, in addition to reducing direct care staffing ratio to 2.5, closing the Canteen, and reorganizing therapy departments to allow fewer supervisory positions were reported to the Interim Joint Labor, Health, and Social Services Committee in Director Forslund’s 2014 annual report on the WLRC. More recent reports could not be located at the time of this writing.
            Members of Friends of the Wyoming Life Resource Center (FWLRC) and other guardians have been asking about staffing for the past 3 years.  Consistently we are told that the center is fully staffed – the problem is deployment and utilization rather than the number of Direct Support Professionals (DPSs) employed. We have long debated whether or staffing ratios are supposed to include supervisors, trainers, medication aids and other support staff (therapy aids, etc.). (Regulations and Guidance available at  Moreover, guardians question the definition of fully staffed – does this mean the center has employed all the DSPs necessary to provide adequate care and assistance or does it mean they have hired the number of DSPs as allowed by the Department of Health? The reports from WDH do not clearly define their staffing ratios.  Instead of stating the ratios in a format which reflects that of the Federal Code of Regulations, staffing ratios are given as a single number, i.e. 2.5. Currently, there are 75 individuals living at the WLRC, including those in the Acquired Brain Injury Program. The Department of Health states there are 190 DSPs, Lead Workers (trainers), and Supervisory Staff employed at the WLRC. The Code of Federal Regulations is clear.  “Direct care staff must be provided by the facility in the following minimum ratios of direct care staff to clients: …for profoundly retarded clients, clients with severe physical disabilities, or clients who are aggressive, assaultive, or security risks, or who manifest severely hyperactive or psychotic-like behavior, the staff to client ratio is 1 to 3.2.” (C.F.R §483.430(d)(3))
            Last May, Centers for Medicare/Medicaid Services conducted a survey of WLRC in response to numerous complaints.  Their report ( indicated some deficiencies were the direct result of “not having enough staff.” These included immediate jeopardy and allowing staff to continue to work with clients before an investigation was completed. In fact, this survey gave rise to a 90 day intent to terminate participation in the Intermediate Care Facility for Individuals with Intellectual Disability program – meaning the state would lose its license and matching federal funds. In response to this, the Department of Health retained the services of a consulting firm to “fix” the deficiencies in order to avoid those losses. During the time in which CMS surveyors were expected to return, staff was not allowed to take planned vacations and mandatory overtime became normal operating procedure. These administrative actions provided the illusion of sufficient staff ensured the mandated ratios were met.  In fact, guardians are still observing staff shortages in the cottages as well as shortages in professional staff (i.e. physical therapist, occupational therapist, dietician, etc.) and support staff (maintenance, groundskeepers, etc.).Additionally, in two residential areas, staff have a six day work week which entails a mandatory eight hours overtime each week.
            When asked about turnover, administration officials have stated the reason people are quitting is they can get paid more working at McDonalds or they just didn’t want to be there in the first place.  We know that the State of Wyoming offers a competitive wage and benefits package which McDonalds and other employers in Fremont County cannot match. We also know that many of the employees who have resigned or retired are tenured, dedicated, and compassionate individuals. We’ve been told exit interviews are being conducted however, former employees report this is not the case. This is an indication of the apathetical attitude regarding retention.
            A new psychologist has been hired and will begin working on December 1, 2016. One of his first tasks will be a review of everyone who has 1:1 staffing to determine whether or not those individuals actually require it.  According to the consultant hired to address the CMS deficiencies, “Every person here on 1:1 staffing takes up 20 shifts per week and drains staffing.” (Guardians’ Meeting, September 12, 2016). It appears that the Human Resources Department and administrators have no motivation to ensure client safety, active programming, staff recruitment, or staff retention. The Wyoming Department of Health consistently ignores and denies staffing issues at WLRC.
            To make matters worse; plans to move individuals with Dual Diagnosis (Developmental/Intellectual Disability and a psychiatric diagnosis) from the State Hospital to WLRC are moving forward. So far, two 5 bedroom cottages have been remodeled for these new cohorts. The date to commence the move is to be determined however; new hires are being flagged for the Pathways program. In my estimation, these plans should be suspended until such time there are sufficient staff for existing programs (Canyons, Visions, and Horizon Healthcare Center) and a sufficient number of staff are hired and trained to appropriately respond to the behaviors and needs of those with Dual Diagnosis. We have noticed an increase in injuries inflicted by clients on employees and other clients. To move forward without ensuring there are enough staff to deliver adequate supervision and care to all residents is a blatant disregard of the federal regulations and a startling lack of concern for the health, welfare, and safety of those who live and work at the Wyoming Life Resource Center.
            There is no excuse for the lack of appropriate staff at the WLRC nor is there any reason the Department of Health should ignore the recruitment and retention issues there. Nearly eleven years ago, the Office of the Assistant Secretary for Planning and Evaluation released a report on  titled, “The Supply of Direct Support Professionals Serving Individuals with Intellectual Disabilities and Other Developmental Disabilities: Report to Congress.” ( This report compiled surveys and studies of Direct Support Professionals in facilities and home and community based services (HBCS) across the nation. This report attempted to calculate the demand for DSPs through the year 2020.  “At current rates of turnover, 96% of all DSPs hired between 2003 and 2020 will be hired to replace DSPs who leave existing positions (and the people with ID/DD they were supporting).” Staff turnover is a significant driver of demand for DSPs and understanding the factors associated with turnover is essential because reducing turnover can substantially reduce the demand for DSPs in the future. Furthermore, the report stated, “Retention is a key component to meeting increased DSP demand,” while recognizing that “staff turnover… has negative effects on the lives of people with ID/DD” and efforts to retain staff will contribute to maintaining the skills and experience that which are “essential to DSP performance.”  This report also outlined the factors associated with recruitment and retention of DSPs to meet the projected demand. “…DSP turnover was associated with pay (appearing in five of the eight studies), support needs of individuals (four studies), facility size, number of DSPs or ratios of DSPs to people supported (four studies), ICF/MR certification (two studies), urban versus rural location (two studies), how long the site had been open (two studies), and eligibility for paid leave or health benefits (two studies). Other factors associated with turnover were age of people supported, public versus private operation, supervisor tenure, unionization, hours of training provided, and the use of shift versus live in employees.” (Emphasis added) Possibly the most telling statement in this report is, “Perhaps the most detrimental workforce challenge is the high turnover of DSPs, which hinders the development and maintenance of relationships, the development of mutual respect between DSPs and individuals who receive support and their family members, and the development of trust between supported individuals and every new DSP that enters their life. High vacancy rates, an increased use of overtime, and DSP turnover rates averaging 50% or more have negative effects on the quality of supports provided.47 “  

            Recruitment and retention is the direct responsibility of the human resources department. Most, if not all, guardians expect this department to do everything in their power ensure the safety of our loved ones by hiring and retaining a sufficient number of employees to provide their care. There are numerous resources available on the internet.  For example, the National Association of Direct Support Professionals (NADSP) provides tools for recruitment and retention on their website. ( These include a workforce status and outcomes assessment, employee satisfaction survey, exit interview, and a new employee survey – all tools to determine where improvements can be made in recruitment, training, and retention of employees. The rate of turnover at WLRC is alarming. The indifference to the concerns of guardians is appalling. There is no perceivable, plausible deniability on the part of administration.  To no avail, guardians have consistently shared their concerns regarding staffing ratios and the correlation to human resources department practices.  The refusal by the Wyoming Department of Health to address and correct these issues, putting our loved ones at risk, is nothing short of unconscionable. 

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Wednesday, June 29, 2016

90 Day Intent to Terminate ICF licensure and funding

Oh my!  It has been a long time since I posted anything and so much has happened!  Sometimes there is just too much going on to slow down.

The Wyoming Life Resource Center used to be one of the best facilities for Individuals with Intellectual Disabilities.  Used to be.

Over the past nearly three years, guardians and family members have been voicing their concerns over overcrowding, insufficient staffing,  and loss of active treatments. We were patronized and half-heartedly placated.  We were also complacent.  As the Department of Health held us hostage with our fear of closure, we did not voice our concerns loud enough, persistent enough.
We can no longer afford to be complacent in our advocacy efforts.  Things really took a turn for the worse in January, when we had yet another Interim Superintendent walk through that revolving door. We didn't notice how bad it was until April, when my aunt fell very ill.
We were alarmed.  We were overwhelmed.  We saw some of our worst fears realized and weren't really sure where to turn.  Once again, we found ourselves writing to our governor.  We reached out to our legislators. Representatives of the Department of Health continued to spew rhetorical answers to our questions and concerns.
Then Protection and Advocacy Systems, Inc. showed up. We were torn between facing our fears of closure and facing fears that our loved ones were at risk.  For some, the risk of death far outweighed any risk of closure.  For others, fear of closure prevented them from speaking up. The P&A investigation culminated in a call for our governor to immediately institute reform to ensure the safety and well-being of the clients served at the Life Resource Center.
Last month, federal surveyors from Centers for Medicaid/Medicare services came to Wyoming and performed their own investigation.  Imminent jeopardy. Deficiencies. 90 day intent to terminate.  Not in compliance for participation in the ICF program.  Our heads were, and still are, spinning.
The Senior Administrator of the Behavioral Health Division in the Department of Health assured us the necessary corrective actions would be taken to bring the facility into compliance with ICF regulations.  Consultants were hired.  The consultant who is to serve as Interim Superintendent, until a permanent one can be hired, came in to prepare and submit the plan of corrective action with CMS then left again.  We are told he will return the second week of July.  In the meantime, the individual who was serving as Interim Superintendent (and should be held accountable for the entire CMS report) is in charge until this consultant returns.
And so we wait with baited breath. Is there something more we can do? How do we ensure that our voices are heard in the future? How do we protect our loved ones with a departmental administration who refuses to take seriously our concerns?  How do we convince legislators that our loved ones are living, breathing, feeling human beings and not just numbers?

Monday, March 14, 2016

Developmental Disabilities: What You Should Know

March is National Developmental Disabilities Awareness Month, so proclaimed by President Ronald Reagan in 1987.  This is the month in which advocates across the U.S. really focus their efforts to build awareness and acceptance in their communities. One important aspect of raising awareness is educating our fellow citizens.  Let’s first talk about what developmental disabilities are.

            The Centers for Disease Control defines Developmental Disabilities as “a group of conditions due to an impairment in physical, learning, language, or behavior areas.”

A complex mix of factors are thought to be the cause of developmental disabilities; genetics, parental health and behaviors during pregnancy, complications during birth, infections the mother might have during pregnancy or the baby might have very early in life, and exposure of the mother or child to high levels of environmental toxins.  For the most part, the cause or causes of developmental disabilities is unknown.

            One criterion for determining developmental disability is found in the Americans With Disabilities Act: “Results in substantial functional limitations in three or more of the following areas of major life activity:
(i) Self-care;
(ii) Receptive and expressive language;
(iii) Learning;
(iv) Mobility;
(v) Self-direction;
(vi) Capacity for independent living; and
(vii) Economic self-sufficiency.”

            The CDC estimates 1 in 6 American children have one or more developmental disabilities or other developmental delays.According to the U.S. Census Bureau in a 2010 report, 1 in 5 Americans have a disability.

            The most common conditions which fall under the developmental disabilities designation are:

            Intellectual Disabilities – formerly known as mental retardation,                             intellectual disabilities (ID) limit a person’s ability to learn and function at levels typical for      their chronological age.  The disability is diagnosed in three categories: mild,            moderate, or severe.

            Autism – Autism Spectrum Disorder (ASD) is a group of highly variable     developmental disabilities which creates social, emotional, and behavioral   challenges. Persons with Autism are usually sensitive to sensory stimulation and can be affected by light, sound, and touch.

            Cerebral Palsy – Cerebral Palsy (CP) is a group of disorders which affect a         person’s movement, balance, and posture. Persons with cerebral palsy often also have intellectual disability, seizures, or problems with speech, hearing, or vision.

            Trisomy 21 (Down Syndrome) – Down Syndrome occurs when a child inherits extra genetic material during conception.  This extra chromosome causes delays in mental and physical development. The physical appearance of persons with Down Syndrome varies by individual as does associated medical conditions.

            Spina Bifida (cleft spine) is a condition in which the development of the brain,   spine, or protective covering around them is incomplete. Complications associated with Spina Bifida vary from minor physical problems with minimal impairment to severe physical and mental disabilities.

            ADHD - The Centers for Disease Control also list ADHD as a developmental        disability; though not everyone agrees with this designation.  Persons with ADHD      (Attention Deficit Hyperactivity Disorder) have a difficult time paying attention,             controlling impulsive behaviors, and/or being overly active.  Although there is no cure,   ADHD can be managed with medication and behavior therapy.

             Understanding developmental disabilities (DD) is the first step in accepting and integrating persons with DD into our communities.  Here are some ways you can support persons with developmental disabilities:

            1.         Take the time to educate yourself and others about the needs of people with developmental disabilities in Wyoming.  Learn about the issues facing Persons with DD in Wyoming, talk to family members, community program providers, or other advocates such as Friends of WLRC (

            2.         Make sure that your words and actions are respectful of those with developmental disabilities.  Have conversations with your family and friends about the harmful impact of using derogatory language towards people with DD.

            3.         Contact your legislators and congressional delegates.  Let them know you are concerned about continuing publicly funded services in the face of budget cuts and you expect them to enact public policy to assist people with disabilities.

            4.         Take the time to get to know someone with developmental disabilities.  Your understanding and perspective will be positively changed.

            5.         Support businesses that employ people with developmental disabilities and make sure they know you noticed.

            6.         Conduct community-based activities such as campaigns in your school or business.

            7.         Write a blog post about someone you know with a developmental disability and explain how they’ve inspired you.

            8.         “Like” the Friends of Wyoming Life Resource Center’s Facebook page and post this as your Facebook status: I support and celebrate people with developmental disabilities and you should too!



1.         Centers for Disease Control - Definition 

2.         Centers for Disease Control – Causes  

3          Florida Developmental Disabilities Council – Federal Definition      

4.         U.S. Census Bureau – 2010 Report

5.         Centers for Disease Control – Specific Conditions


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Sunday, February 14, 2016

Budget Cuts Cause Crisis

There's a nationwide crisis for individuals with I/DD and ABI. So many states are working on their budgets...and cutting funds for programs and services for these people. Wyoming, Wisconsin, California, Connecticut...just to name a few. The care of these vulnerable people becomes a partisan issue. 

The cuts in funding have a wide and negative impact on these people and those who serve them; from staffing issues to reductions in the kinds of services offered. Persons with intellectual and developmental disabilities or acquired brain injuries deserve better. Their care should not be a partisan issue. Nor should it be at the bottom of the list of priorities for our state lawmakers. 

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Thursday, January 14, 2016

What is the Joint Committee Missing?

Granted, there are exceptions, however; the Joint Labor, Health, and Social Services Committee seems to allow the Department of Health to force feed them; twisting words and statistics in order to legitimize its agenda. So what is the committee missing?

1.  The Supreme Court's decision in Olmstead does not require states to close state run facilities for the developmentally disabled. It is not, as a Dept. of Health analyst put it, "A decision for nationwide deinstitutionalization." Olmstead has been misinterpreted and the committee members, having been told such, should look at the decision themselves rather than accept what a policy analyst tells them. It has become abundantly clear that the Department has an agenda which includes phasing out the state's only ICF/IID.

2.  The Department is willing to risk an IMD designation and lose the ICF/IID licensure because the Director's plan is to phase out the ICF/IID. While members of the committee believe the plan is to keep a minimum number of beds for individuals with profound disabilities as a " safety net," the Director's plan appears to turn the facility into an annex of our State Hospital, which is an IMD. 

3.  The Department has suggested removing choice from the statutes in an effort to keep guardians from choosing the ICF/IID for their wards even if the placement would be the most appropriate, most integrated, and least restrictive environment as required by the Olmstead decision. The Department has contended that there are, in fact, individuals currently being served at the Life Resource Center who should have been transitioned to community programs but guardians objected; putting unnecessary financial burdens on our state. 

4.  The Department has also suggested taking the Interdisciplinary Team out of the process in applying for admission and making the Department the only assessor of appropriateness. Although guardians are part of the team, they cannot simply override the rest of the team when making a determination. Currently, the team is comprised of professionals experienced with developmental disabilities, (WLRC staff), as well as representatives from the Department. 

5.  The Facilities Task Force recommended placing all of the state's facilities on an enterprise funding model and assessing the true cost of each to the state. In response to questions regarding WLRC's revenue, the Dept. of Health has stated those figures are unavailable to saying now they have those figures but never once producing them. In regards to other facilities, the Dept. has gone from saying how costly they are to now saying the Retirement Center and Veterans' Home are self-sufficient. 

6.  While the Dept. and the LHSS Committee have called the current residents at WLRC the "legacy population," and deemed them safe from forced transitions; the Dept. has systematically destroyed the very aspects of the center which made it one of the best in the nation. That, coupled with Director Forslund's statement that he will proceed with his plans whether or not the new buildings are funded, it is even more clear he is determined to make the Life Resource Center a facility for those with psychiatric diagnoses to the detriment of the profoundly disabled individuals who would otherwise be served at the WLRC. 

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Monday, January 11, 2016

The New State Hospital Annex

I have to preface this post with the opinion/viewpoint expressed here is purely my own and is not reflective of the organizations to which I belong.  That being said...
For several years, advocates in Wyoming have been doing their best to keep the state from closing the state's only ICF/IID, the Wyoming Life Resource Center (WLRC).  The state legislature has spent literally millions on studies trying to determine whether keeping the center open is a viable option and later, to determine the capital construction needs of the center; finally to determine how to construct a facility that will meet the new "mission" of the WLRC.  The plan is to add new cohorts to the facility - Title 25 (civil commitments) and geropsych patients.  This plan is the result of efforts of the Facilities Task Force (FTF) over the past two years.  As one can imagine, this is a multi-faceted issue.
First, what happens to those who are currently residents at the WLRC?  Some have been there nearly all their lives.  The Department of Health (DoH) determined forcible transition would put those people at risk so the FTF has created a "legacy population" who will be allowed to remain at the center. This legacy population is comprised of those with "organic brain syndrome" or acquired brain injuries, profoundly intellectually disabled persons with high medical needs, developmentally disabled persons with difficult behaviors, and those few higher functioning who have lived their entire lives at the center.  The projections provided by the DoH show that this population will decrease to almost zero (currently there are around 80 residents) in about 20 years due to mortality. I believe that the decision to create the "legacy population" was an attempt to placate the vocal advocates and guardians of the residents of WLRC.  In fact, during my public comment to the legislative committee which deals with health and social services issues, one of the chairpersons indicated that my concerns were unfounded in light of the guarantee of the "legacy population" and their ability to remain at the center, if they so choose.  But our concerns are not just about the "legacy population."
What about future generations of those with profound disabilities and high medical needs?  According to the state's analysts, the need for beds for these individuals will also decrease over time.  In fact, they've allowed only 10 beds at the WLRC for I/DD in the future, after the "legacy population" is no longer an issue. Studies show that there will be ever increasing numbers of children diagnosed with Autism Spectrum Disorder and that there has not been a decrease in the numbers of children born with cerebral palsy.  Nothing indicates a decrease in numbers of children born with a developmental or intellectual disability.  In addition, the population of our state is increasing in the number of elderly citizens; some of which are the parents of adults with I/DD. Common sense would be that this would create a need for an ICF/IID; especially considering that not everyone can be served at home or in the community. But that's a debate for another time. Suffice it to say, I believe there is a need for ICFs as well as home and community based services and that every individual with I/DD and organic brain syndrome (ABI/TBI) deserves integrated, client centered care and has a right to choose where to receive those services.  I also believe it is our responsibility, as a society, to ensure that every service provider is fully funded.
Due to changes made over the past 5 years, staff morale is very low.  Employees who might not have otherwise retired have jumped ship "before it sinks."  The DoH froze 100 positions last summer, leaving many positions unfilled.  Despite guardians' concerns, the state claims they are within staffing ratios and that residents are receiving the same care and services as they always have.  It simply is not true.  Our loved ones are not getting the equine therapy they once did.  There are times that individuals cannot attend aquatic therapy or go to day habilitation due to a lack of staff to take them to these services.  Clients who require one on one staffing often go without their one on one.  To accommodate the decrease in staffing, clients have been moved and are overcrowded in their cottages.  This overcrowding also causes safety concerns.  Equipment (wheelchairs, side-lyers, oxygen concentrators, etc.) fill the common areas and hallways.  At a recent meeting, one guardian summarized, "It is to the point of being inhumane." 
In anticipation of the legislature approving the changes to the mission of the WLRC, the DoH has hired a superintendent and a nurse practitioner with backgrounds in psychiatric services. The architects who performed the latest studies asked the FTF if they really wanted to move the gero-psych and Title 25 to Lander as those populations would require a new staff with a different skill set than the current staff at WLRC.  The superintendent has implied that future staff will be psychiatric nurses and paraprofessionals.
The FTF and DoH have also recommended statutory changes to reflect the new "safety net" mission of the State Hospital and WLRC. Part of the recommended option, in fact, stated it would eliminate guardian choice.  The section which ensured informed choice is being repealed. The multidisciplinary team which determines the appropriateness of placement at the WLRC is also being eliminated; making the DoH the only assessors of appropriateness.  The statutory changes also address the addition of the Title 25 and geropsych patients becoming residents at the WLRC, requiring licensure as a skilled nursing facility (SNF).  The state is waiting on a determination by the Centers for Medicaid/Medicare Services (CMS) as to whether a skilled nursing facility, with psychiatric beds, can be on the same campus as an ICF/IID and retain the reimbursements from CMS.  It is important to note that this change was precipitated by the spike in the number of Title 25 civil commitments in our state and the lack of available space at the State Hospital (psychiatric facility) for these and the geropsych patients.  It appears that the DoH intends to turn the WLRC into an annex of the State Hospital and eliminate the ICF/IID altogether, forcing individuals to receive services at home, in community programs, or in nursing homes. Ironically, the DoH just presented a Waiver Rebasing Report which calls for cuts in Medicaid payments for services in home and community based programs.
Next, let's talk about the legislature; more specifically the Joint Labor, Health and Social Services Committee (LHSS). Stay tuned.

Tuesday, December 8, 2015

State Budget - Get Involved

As lawmakers in Wyoming prepare for the upcoming budget session, it's important to note the Governor's budget; as well as his intention to cut the Department of Health budget. 

The Department of Health is responsible for many programs which serve to improve the health of this state's citizens. The Department has five divisions; Aging, Behavioral Health (which combined the Developmental Disabilities Division), Medicaid, Public Health (combined with Community Health), and Health Care Licensing and Survey. Without a doubt, cuts to the Department's already strained budget will affect a greater number of our population than any other department I can think of. 

Some people question the governor's priorities. It was recently reported that he intends to give the University of Wyoming athletics department $5 million out of the rainy day fund; while intending to cut the state's budget where it hurts most. But we must also consider the priorities of his constituents. Everyone wants something; bigger schools, beautification on our overpasses, wider and faster roads, and so on. 

As we ask ourselves what our state needs most in the forecasted lean years, we need to make sure our representatives and senators know what the people they represent think. It is their job to represent their constituents. If we don't give them our opinion, we have no right to bellyache about the lack of services in our communities; or the fact that Governor Mead wants to use rainy day funds for non-essential purposes. It's important to remember that our elected officials work for us. But how can they govern our state effectively if citizens are not engaged? 

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