aging and long-term support administration · september 9, 2016 page1 of13 plan of correction...
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Completion DateLicense #: 348400
November 30, 2016
1Page 3of
REBECCA‘S ADULT CAREPlan of Correction
STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES
AGING AND LONG-TERM SUPPORT ADMINISTRATION316 W Boone Ave., Suite 170, Spokane, WA 99201
Statement of Deficiencies
Licensee: REBECCA JOHNSON
Rose Anderson, RN, BSN, Licensor
From:
DSHS, Aging and Long-Term Support Administration
Residential Care Services, Region 1, Unit B
316 W Boone Ave., Suite 170
Spokane, WA 99201
(509)323-7324
You are required to be in compliance with all of the licensing laws and regulations at all times to
maintain your adult family home license.
The department has completed data collection for the unannounced on-site follow-up inspection
of: 11/7/2016
REBECCA‘S ADULT CARE
14420 E SUNNYSIDE DR
VERADALE, WA 99037
As a result of the on-site follow-up inspection the department found that you are not in
compliance with the licensing laws and regulations as stated in the cited deficiencies in the
enclosed report.
I understand that to maintain an adult family home license I must be in compliance with all the
licensing laws and regulations at all times.
This document references the following SOD dated: September 9, 2016
The department staff that inspected the adult family home:
DateResidential Care Services
DateProvider (or Representative)
Completion DateLicense #: 348400
November 30, 2016
3Page 3of
REBECCA‘S ADULT CAREPlan of Correction
Statement of Deficiencies
Licensee: REBECCA JOHNSON
received hospice care from an outside agency and experienced frequent pain.
-According to the resident's November 2016 medication log, the resident had routine
medications to assist in controlling pain and an as needed narcotic pain medication. The
initials on the log reflected the resident received 7 doses of the as needed pain medication from
11/1-6/16. However, according the narrative documentation on the back of the medication log,
the resident received 25 doses of the medication during that time frame.
The resident was observed on 11/7/16 up in a , had minimal verbalization and
required staff assistance with mobility.
Caregiver #D was interviewed on 11/7/16 regarding the resident's medication logs and verified
the initials were not reflective of when the narcotic medication was actually given. The staff did
not consistently initial the log when they gave the resident as needed medication.
-The Novmeber 2016 medication log directed the staff to apply an )
twice a day. The staff initialed as if the resident received the medication routinely. However on
11/7/16, the caregiver was unable to find the and said she had not applied it. Staff
initialed for a medicated treatment they did not consistently provide.
3. Resident #2, per The July 2016 assessment, had memory problems and required assistance
with medications.
The Novmeber 2016 medication log was reviewed on 11/7/16 and identified the resident had an
as needed order for . The log contained the dosage but did not identify the frequency the
medication could be provided to the resident.
This is an uncorrected citation from the full inspection 9/9/16
Attestation Statement
I hereby certify that I have reviewed this report and have taken or will take active measures
to correct this deficiency. By taking this action, REBECCA'S ADULT CARE is or will be
in compliance with this law and / or regulation on (Date)________________ . In addition, I
will implement a system to monitor and ensure continued compliance with this cited
deficiency.
Provider (or Representative) Date
Completion DateLicense #: 348400
September 9, 2016
1Page 13of
REBECCA‘S ADULT CAREPlan of Correction
STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES
AGING AND LONG-TERM SUPPORT ADMINISTRATION316 W Boone Ave., Suite 170, Spokane, WA 99201
Statement of Deficiencies
Licensee: REBECCA JOHNSON
Rose Anderson, RN, BSN, Licensor
Carmen Church, Regional Quality Improvement Coordinator
From:
DSHS, Aging and Long-Term Support Administration
Residential Care Services, Region 1, Unit B
316 W Boone Ave., Suite 170
Spokane, WA 99201
(509)323-7324
You are required to be in compliance with all of the licensing laws and regulations at all times to
maintain your adult family home license.
The department has completed data collection for the unannounced on-site full inspection of:
8/18/2016, 8/24/2016, 9/1/2016 and 9/7/2016
REBECCA‘S ADULT CARE
14420 E SUNNYSIDE DR
VERADALE, WA 99037
As a result of the on-site full inspection the department found that you are not in compliance with
the licensing laws and regulations as stated in the cited deficiencies in the enclosed report.
I understand that to maintain an adult family home license I must be in compliance with all the
licensing laws and regulations at all times.
The department staff that inspected the adult family home:
DateResidential Care Services
DateProvider (or Representative)
Completion DateLicense #: 348400
September 9, 2016
2Page 13of
REBECCA‘S ADULT CAREPlan of Correction
Statement of Deficiencies
Licensee: REBECCA JOHNSON
WAC 388-76-10130 Qualifications Provider, entity representative and resident manager.
The adult family home must ensure that the provider, entity representative and resident
manager have the following minimum qualifications:
(11) Obtain and keep valid cardiopulmonary resuscitation (CPR) and first-aid card or certificate
as required in chapter 388-112 WAC; and
Based on observation, interview, and record review, the adult family home failed to ensure first
aid and CPR cards were current for 1 of 1 provider (#A). Findings include:
The provider was observed to live in the home and worked routinely providing direct care to the
residents. Her employee file was reviewed on 8/18/16 and identified her first aid/CPR card
expired in January 2016.
The provider was interviewed at that time and stated she thought it was good until 2017. On
8/24/16, the provider verified her card was expired and said she would take a class as soon as
possible.
Attestation Statement
I hereby certify that I have reviewed this report and have taken or will take active measures
to correct this deficiency. By taking this action, REBECCA'S ADULT CARE is or will be
in compliance with this law and / or regulation on (Date)________________ . In addition, I
will implement a system to monitor and ensure continued compliance with this cited
deficiency.
Provider (or Representative) Date
This requirement was not met as evidenced by:
WAC 388-76-10135 Qualifications Caregiver. The adult family home must ensure each
caregiver has the following minimum qualifications:(7) Have a current valid first-aid and cardiopulmonary resuscitation (CPR) card or certificate as
required in chapter 388-112 WAC; and
Based on interview and record review, the adult family home failed to ensure first aid and CPR
cards were current for 1 of 2 caregivers (#B). Findings include:
Caregiver #B lived in the home and was a back up caregiver. His employee file was reviewed
on 8/18/16 and identified her first aid/CPR card expired in January 2016.
The provider was interviewed at that time and stated she thought it was good until 2017. On
8/24/16, the provider verified his card was expired and said he would take a class as soon as
possible.
This requirement was not met as evidenced by:
Completion DateLicense #: 348400
September 9, 2016
3Page 13of
REBECCA‘S ADULT CAREPlan of Correction
Statement of Deficiencies
Licensee: REBECCA JOHNSON
Attestation Statement
I hereby certify that I have reviewed this report and have taken or will take active measures
to correct this deficiency. By taking this action, REBECCA'S ADULT CARE is or will be
in compliance with this law and / or regulation on (Date)________________ . In addition, I
will implement a system to monitor and ensure continued compliance with this cited
deficiency.
Provider (or Representative) Date
WAC 388-76-10175 Background checks Employment Conditional hire Pending results
of Washington state name and date of birth background check. An adult family home may
conditionally employ a person directly or by contract, pending the result of a Washington
state name and date of birth background check, provided the home:
(3) Does not allow the individual to have unsupervised access to any resident;
Based on observation, interview, and record review, the adult family home failed to ensure date
of birth background check results were received prior to 1 of 3 sample caregivers (#D) having
unsupervised access to the residents. The deficient practice placed residents at risk of coming
into contact with someone that had a negative finding on the results. Findings include:
On 8/18/16 Caregiver #C was the primary caregiver and Caregiver #D was training to work in
the home. Caregiver #D was intermittently left unsupervised by other staff in various rooms
with the residents.
The provider was interviewed at the time and stated she did not realize the caregiver had to have
direct supervision before background check results were obtained. She sent the caregiver home
after the licensor identified the concern.
Attestation Statement
I hereby certify that I have reviewed this report and have taken or will take active measures
to correct this deficiency. By taking this action, REBECCA'S ADULT CARE is or will be
in compliance with this law and / or regulation on (Date)________________ . In addition, I
will implement a system to monitor and ensure continued compliance with this cited
deficiency.
Provider (or Representative) Date
This requirement was not met as evidenced by:
Completion DateLicense #: 348400
September 9, 2016
4Page 13of
REBECCA‘S ADULT CAREPlan of Correction
Statement of Deficiencies
Licensee: REBECCA JOHNSON
WAC 388-76-10225 Reporting requirement.
(1) The adult family home must ensure all staff:
(a) Report suspected abuse, neglect, exploitation or abandonment of a resident:
(i) As required by chapter 74.34 RCW;
(ii) To the department by calling the complaint toll-free hotline number; and
(iii) To the local law enforcement agency when required by RCW 74.34.035 .
Based on interview and record review, the adult family home failed to report suspected verbal
abuse to the department's hot-line for 1 of 5 sample residents (#3). The deficient practice placed
residents at risk for ongoing verbal abuse. Findings include:
Resident #3, per record review, had memory problems, required assistance with activities of
daily living, and had a variety of behavioral problems that required staff intervention to prevent
escalation.
During an interview with the provider on 8/18/16, she stated a former caregiver was mean to the
resident causing to have an increase in behavioral outbursts. She said another resident (#4)
notified her of the incidents after the caregiver no longer worked in the home (February 2016).
Resident #4 was interviewed on 8/24/16 regarding staff treatment of self and other residents.
stated there was a former caregiver that was mean and yelled at Resident #3. Resident #4
verified had not told anyone until after the caregiver no longer worked in the home. said
felt like could talk with the provider about anything and was not sure why had
waited to tell her.
The provider was interviewed per telephone on 9/7/16 regarding the allegations and stated she
believed the former caregiver did interact with Resident #3 inappropriately. She said she called
in missing medications to the state hot-line around the same time and thought she had reported
the verbal abuse also. Upon further discussion, she said she might have just told the state
investigator when he came to the home. The provider was unsure if she phoned the hot-line
specifically in regards to the suspected verbal abuse.
Review of the department's records showed no indication the suspected verbal abuse was
reported by the home.
This requirement was not met as evidenced by:
Completion DateLicense #: 348400
September 9, 2016
13Page 13of
REBECCA‘S ADULT CAREPlan of Correction
Statement of Deficiencies
Licensee: REBECCA JOHNSON
office (9/9/16), the instructions on the separate form were not consistent with what the staff were
actually doing.
The medication log did not contain complete information regarding the resident's
dosages or the amount of received when staff gave it.
2. Resident #1, per record review, had memory problems, required total assistance with
activities of daily living and staff administered medications. The resident received hospice
care from an outside agency and experienced frequent pain.
According to the resident's August 2016 medication log, the resident had routine medications to
assist in controlling her pain and an as needed narcotic pain medication.
Caregiver #D was observed to provide the resident with the as needed pain medication on
8/18/16. She wrote a narrative entry on the back of the medication log, but did not initial the
log. Further review of the medication log identified the staff consistently did not initial the log
when the as needed medication was given.
The caregiver was interviewed on 9/1/16 regarding the resident's as needed medication. She
verified the staff did not initial the front of the log when they gave the medication.
3. Resident #2, per record review, was alert, had memory problems, and required assistance
with medications. The resident had diagnoses including .
The August 2016 medication log was reviewed on 8/18/16 and identified the resident had an as
needed treatment. The log did not contain the frequency the medication could be
provided to the resident.
Attestation Statement
I hereby certify that I have reviewed this report and have taken or will take active measures
to correct this deficiency. By taking this action, REBECCA'S ADULT CARE is or will be
in compliance with this law and / or regulation on (Date)________________ . In addition, I
will implement a system to monitor and ensure continued compliance with this cited
deficiency.
Provider (or Representative) Date
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