Summit Supportive Communities

An initial certification of the supportive living program was completed on 2/9/23. A deficiency was cited. Based on interview and record review, the residence failed to be in compliance with all applicable regulations.This failure created the potential for mismanagement of the care and services for the residents who would be served by this residence.Findings include:The following was found during record review:-8.515.85.G STAFFING4. Within one month of the date of hire, the SLP provider shall provide adequate training for staff on each of the following topics:a. Crisis prevention;b. Identifying and dealing with difficult situations;c. Cultural competency.On 2/9/23 at approximately 12:00 p.m., the assistant administrator (AA) was asked to provide staff training related to crisis prevention, identifying and dealing with difficult situations and cultural competency. However, no such training documentation was provided by the time of exit on 2/9/23 at 2:30 p.m.On 2/9/23 at approximately 2:15 p.m., the AA stated she was not aware of the staffing requirement for staff who worked with residents with brain injuries. -8.515.85.G STAFFING7. In addition to the requirements of 6 CCR 1011-1 Ch. 7 , the Department requires that the program director shall have an advanced degree in a health or human service related profession plus two years of experience providing direct services to persons with a brain injury. A bachelor' s or nursing degree with three years of similar experience, or a combination of education and experience shall be an acceptable substitute.On 2/9/23 at approximately 9:30 a.m., the AA identified the administrator of record as the program director. The AA was asked to provide the program directors qualifications, per the regulation. The AA was not aware of this regulation and stated she would reach out to the program director for this information.On 2/9/23 at approximately 2:15 p.m., no training documentation or other information was provided by the AA to show proof that the program director met the requirements.