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Residential Care Services Investigation Summary Report
Citation written for 388-76-10400 (2) Care and Services; 388-76-10355 (1) (2) (3) failure to provide caregiver accompanimentsto named resident's mental health appointment visits.
Page 2 of 2
Completion DateLicense #: 750538
August 3, 2016
1Page 4of
BENSON HILL AFHPlan of Correction
STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES
AGING AND LONG-TERM SUPPORT ADMINISTRATION20425 72nd Avenue S, Suite 400, Kent, WA 98032-2388
Statement of Deficiencies
Licensee: ANDRIAN CHAGAY
Julie Miranda, BSN, RN, AFH Licensor
From:
DSHS, Aging and Long-Term Support Administration
Residential Care Services, Region 2, Unit G
20425 72nd Avenue S, Suite 400
Kent, WA 98032-2388
(253)234-6007
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 complaint
investigation of: 7/15/2016
BENSON HILL AFH
10923 SE 183RD CT
RENTON, WA 98055
As a result of the on-site complaint investigation 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 complaint number: 3203892
The department staff that inspected and investigated the adult family home:
DateResidential Care Services
DateProvider (or Representative)
Residential Care Services Investigation Summary Report
Provider/Facility: BENSON HILL AFH (687935) Intake ID(s): 3243282
License/Cert. #: AF750538Investigator: Miranda, Julie Region/Unit: RCS Region 2/Unit G Investigation
Date(s):07/08/201607/18/2016
through
Complainant Contact Date(s): 07/18/2016Allegations:1. Named resident alleged a caregiver, "Being mean to hurt me and hit me on my
Investigation Methods:Sample: Named resident and 2
other current residents.Observations: Named resident and 2
other current residents,caregivers providing careand their interaction withresidents.
Interviews: Named resident, 2 othercurrent residents,caregivers, Provider.
Record Reviews: Named resident and 2other current residents'records, assessments andcare plans, abuse andneglect policies andreporting.
Allegation Summary:Based on observations, interviews and record reviews, allegations of abuse by named resident was not substantiated.Caregivers provided care to residents in a respectful and appropriate manner. Interviews with named resident and 2 otherresidents stated no experience or incidents of abuse at the AFH. Review of abuse policies showed abuse statements andreporting requirements. Interview with caregivers and Provider showed compliant with abuse policies and reportingrequirements. No failed practice identified with the allegation, citations were written for unalleged violations.
Unalleged Violation(s):A citation was written for a sampled resident's NCP not updated on a yearly basis as required. 388-76-10380 (4); 388-76-101632 (1) National Fingerprint background check required, 388-76-10130 (8)- newly hired Resident Manager had notcompleted the one thousand hours experience requirement since hire date.
Yes No
Page 1 of 2
Residential Care Services Investigation Summary Report
Conclusion /Action:
Failed Provider Practice Identified /Citation(s) Written
Failed Provider Practice Not Identified /No Citation Written
A citation was written for a sampled resident's NCP not updated on a yearly basis as required. 388-76-10380 (4); 388-76- 101632(1) National Fingerprint background check required, newly hired resident Manager had not completed the requirements sincehire date.
Page 2 of 2
Completion DateLicense #: 750538
July 18, 2016
1Page 5of
BENSON HILL AFHPlan of Correction
STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES
AGING AND LONG-TERM SUPPORT ADMINISTRATION20425 72nd Avenue S, Suite 400, Kent, WA 98032-2388
Statement of Deficiencies
Licensee: ANDRIAN CHAGAY
Julie Miranda, BSN, RN, AFH Licensor
From:
DSHS, Aging and Long-Term Support Administration
Residential Care Services, Region 2, Unit G
20425 72nd Avenue S, Suite 400
Kent, WA 98032-2388
(253)234-6007
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 complaint
investigation of: 7/8/2016 and 7/18/2016
BENSON HILL AFH
10923 SE 183RD CT
RENTON, WA 98055
As a result of the on-site complaint investigation 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 complaint number: 3243282
The department staff that inspected and investigated the adult family home:
DateResidential Care Services
DateProvider (or Representative)
Completion DateLicense #: 750538
July 18, 2016
2Page 5of
BENSON HILL AFHPlan of Correction
Statement of Deficiencies
Licensee: ANDRIAN CHAGAY
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:
(8) Have completed at least one thousand hours of successful direct care experience in the
previous sixty months obtained after age eighteen to vulnerable adults in a licensed or contracted
setting before operating or managing a home. Individuals holding one of the following
professional licenses are exempt from this requirement:(a) Physician licensed under chapter 18.71 RCW;
(b) Osteopathic physician licensed under chapter 18.57 RCW;
(c) Osteopathic physician assistant licensed under chapter 18.57A RCW;
(d) Physician assistant licensed under chapter 18.71A RCW;
(e) Registered nurse, advanced registered nurse practitioner, or licensed practical nurse licensed
under chapter 18.79 RCW.
Based on observation, interview and record review, the adult family home (AFH) failed to
ensure the Resident Manager completed at least one thousand hours of successful direct care
experience in the previous sixty months before managing or operating a home. This placed
residents at risk for compromised care and possible abuse and neglect and its complications.
Findings include:
On observation, the AFH provided care to Resident #1, #2 and #3 with
and .
Resident Manager interacted and communicated with Residents #2 and #4 during investigation.
On record review, she was hired as a Resident Manager dated 3/21/2016.
On interview with the Resident Manager, she stated she came in everyday to the AFH and set up
residents' appointments, arranged transportation and accompanied residents to their
appointments. She provided care to the residents, assisted them with showers and dressing,
cooked meals in emergency cases if other caregivers were not available. She developed care
plans, residents' application needs and completed admission agreements. She added she worked
as a previous caregiver to the AFH in 2006 through 2009. She then took a maternity leave,
worked at a child home day care until 2015.
She then was hired to the AFH as a Resident Manager dated 3/21/2016, 84 months since her last
role as a caregiver to the home. She acknowledged she had not completed at least one thousand
hours of successful direct care experience in a vulnerable adults setting in the previous 60
months.before assuming the role as a Resident Manager.
This requirement was not met as evidenced by:
Completion DateLicense #: 750538
July 18, 2016
3Page 5of
BENSON HILL AFHPlan of Correction
Statement of Deficiencies
Licensee: ANDRIAN CHAGAY
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, BENSON HILL AFH 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 388-76-10380 Negotiated care plan Timing of reviews and revisions. The adult
family home must ensure that each resident's negotiated care plan is reviewed and revised
as follows:
(4) At least every twelve months.
Based on observation, interview and record review, the adult family home (AFH) failed to
ensure 1 of 4 residents' (Resident #2) Negotiated Care Plan (NCP) was updated every 12 months
as required by regulations. This placed the resident at risk for compromised care and unmet care
needs.
Findings include:
All observation, interview and record review occurred on 7/8/16, 7/15/2016 and 7/18/2016
unless otherwise noted.
Resident #2 was admitted to the AFH dated /09 with multiple diagnoses and included
On observation of the resident, was alert, and to
communicate with caregivers and other contacts.
On review of Resident #2's NCP, the last update was completed dated 2/28/2015, 4 months and
8 days overdue from the last update. The NCP regarding "Care and Services" showed, "The Case
Manager indicated that client has ." No update or review regarding this
behavior was addressed if the resident continued or no longer indicated
any progress or improvement or other continuing behavior issues. All other areas in care were
not also updated if there were any changes or identified concerns with care.
During interview with the Resident Manager, she acknowledged that Resident's NCP was not
updated on a yearly basis and other revision that needed to be completed.
This requirement was not met as evidenced by:
Completion DateLicense #: 750538
July 18, 2016
4Page 5of
BENSON HILL AFHPlan of Correction
Statement of Deficiencies
Licensee: ANDRIAN CHAGAY
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, BENSON HILL AFH 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 388-76-101632 Background checks National fingerprint background check.
(1) Individuals specified in WAC 388-76-10161 (2) who are hired after January 7, 2012 and are
not disqualified by the Washington state name and date of birth background check, must
complete a national fingerprint background check and follow department procedures.
Based on observation, interview and record review, the adult family home (AFH) failed to
ensure 1 of 3 staff (Resident Manager) had completed a national fingerprint background check
upon hire as required. This placed the residents at risk for harm from a Resident Manager with
an unknown fingerprint-based background check.
Findings include:
Observations, interviews and record reviews occurred on 7/8/2016, 7/15/2016 and 7/18/2016.
On observation, Resident Manager provided care, interaction and communicated with Residents
#2 and #4 at the AFH.
Resident #1 was out of the AFH during investigation, on interview with Resident Manager she
stated she provided care, interaction and communication with Resident #1 also.
On record review, Resident Manager had not completed a national fingerprint background check
since hire date dated 3/21/2016 and on interview with the Resident Manager, she verified that
she had not completed the fingerprint background check as required since she started her role as
the Resident Manager of the AFH.
This requirement was not met as evidenced by:
Completion DateLicense #: 750538
July 18, 2016
5Page 5of
BENSON HILL AFHPlan of Correction
Statement of Deficiencies
Licensee: ANDRIAN CHAGAY
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, BENSON HILL AFH 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
Residential Care Services Investigation Summary Report
Provider/Facility: BENSON HILL AFH (687935) Intake ID(s): 3187118
License/Cert. #: AF750538Investigator: Zeile, Louise Region/Unit: RCS Region 3/Unit A Investigation
Date(s):03/01/201603/19/2016
through
Complainant Contact Date(s): 02/19/2016Allegations:Issue #1: AV is not allowed to have visitors all day.Issue #2: AP changes the visiting hours of the facility.Issue #3: AP is yelling at the AV.Issue #4: AP will not allow AV to get a communications monitor.Issue #5: AP wants to charge AV for the internet.Issue #6: AP is trying to get the AV to sign a contract.
Investigation Methods:Sample: 2 of 4 current residents Observations: Residents, staff to
resident interaction,common areas of thehome and residentrooms.
Interviews: Staff, residents andothers not associatedwith the home.
Record Reviews: Resident records, facilityrecords.
Allegation Summary:Observation, interview and record review did not reflect failed practice related to resident's ability to have visitors nor didinvestigation find evidence of residents being yelled at by the Provider in the home. Investigation did find that video monitoringequipment was not currently working but, the Provider was actively seeking to have it fixed and the home was not at fault forthe technical dysfunction of that system nor was there any finding that the Provider was inhibiting the AV from obtaining acommunications monitor. Allegation regarding the charging of internet services were not substantiated. Investigation found thatAV's Admission Agreement was not currently signed by the AV's Power of Attorney and Provider said that POA had a copy of theAdmissions Agreement (contract) but, had not yet returned it.
Page 1 of 2
Residential Care Services Investigation Summary Report
Unalleged Violation(s):See Statement of Deficiencies dated March 22, 2016.
Yes No
Conclusion: Failed Provider Practice Identified Failed Provider Practice Not Identified
WAC 388-76-10220(3) - Incident log.WAC 388-76-10225(2)(f)WAC 388-76-10225(4)WAC 388-10355(7)(a)WAC 388-76-10400(2)
No Citation WrittenCitation(s) WrittenAction:See Statement of Deficiencies, dated March 22, 2016
Recommend Close InvestigationRecommend FindingRCPP Action:
Page 2 of 2
Completion DateLicense #: 750538
March 24, 2016
1Page 4of
BENSON HILL AFHPlan of Correction
STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES
AGING AND LONG-TERM SUPPORT ADMINISTRATION20425 72nd Avenue S, Suite 400, Kent, WA 98032-2388
Statement of Deficiencies
Licensee: ANDRIAN CHAGAY
Louise Zeile, BSN, Complaint Investigator
From:
DSHS, Aging and Long-Term Support Administration
Residential Care Services, Region 2, Unit G
20425 72nd Avenue S, Suite 400
Kent, WA 98032-2388
(253)234-6007
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 complaint
investigation of: 3/1/2016 and 3/19/2016
BENSON HILL AFH
10923 SE 183RD CT
RENTON, WA 98055
As a result of the on-site complaint investigation 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 complaint number: 3187118
The department staff that inspected and investigated the adult family home:
DateResidential Care Services
DateProvider (or Representative)
Completion DateLicense #: 750538
March 24, 2016
3Page 4of
BENSON HILL AFHPlan of Correction
Statement of Deficiencies
Licensee: ANDRIAN CHAGAY
not been administered medications by the AFH for the entire month of March nor for 4 days at
the end of February. RM said that family member picked up Res #4's medications and that an
'A', which stood for absent was noted on the MAR. Observation of the MAR revealed 'A' on
every day for the month of March and the end of February.
On visit to the AFH on , Res #4 was not observed at the AFH. RM said that Res #4 was
still staying with a family member.
When RM was asked if the department had been notified about Res #4 absence from the AFH,
RM said that the Provider/Entity Representative (ER) had called the department.
Review of DSHS computer software system (CARE) revealed that ER called the department on
and notified the department that the resident was staying with family and would return to
the AFH soon.
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, BENSON HILL AFH 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 388-76-10380 Negotiated care plan Timing of reviews and revisions. The adult
family home must ensure that each resident's negotiated care plan is reviewed and revised
as follows:
(2) When the plan, or parts of the plan, no longer address the resident's needs and preferences;
Based on interview and record review, the Provider failed to update the negotiated care plan
(NCP) for 1 of 4 residents (Resident #3) when the NCP no longer addressed the residents' needs
or preferences. This failure placed residents at risk of not receiving care and services consistent
with their current assessed needs and preferences.
Findings include:
Interview and record review occurred between 3/1/16 and 3/19/16, unless otherwise indicated.
Resident #3 (Res #3) moved into the Adult Family Home (AFH) on 10 with multiple
medical conditions including and
On 3/19, Res #3 said that hurt and that the RM would not help .
This requirement was not met as evidenced by:
Completion DateLicense #: 750538
March 24, 2016
4Page 4of
BENSON HILL AFHPlan of Correction
Statement of Deficiencies
Licensee: ANDRIAN CHAGAY
In interview on 3/19/16, the Resident Manager (RM) said Res #3 did not want the RM to touch
the bandage or assist with changing the dressing. RM said that she offered to help but, Res #3
resisted the help.
In review of Res #3 NCP, there were no updates in the NCP regarding care and no plan to
address the resident's resistance to care.
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, BENSON HILL AFH 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