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,

(https://health.wyo.gov/wp-content/uploads/2016/04/14664_WDHWLRCStudy2013-1.pdf)

            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.

(http://legisweb.state.wy.us/InterimCommittee/2014/WDH-WLRCServices.pdf)  

            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 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/som107ap_j_intermcare.pdf)  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 (https://ohlssurvey.health.wyo.gov/NonSecure/PublicDisplay.aspx?SurveyId=5195) 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.” (https://aspe.hhs.gov/basic-report/supply-direct-support-professionals-serving-individuals-intellectual-disabilities-and-other-developmental-disabilities-report-congress#current) 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. (https://www.nadsp.org/library/tools-and-resources.html) 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. 

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.