AGING AND LONG-TERM SUPPORT ADMINISTRATION · September 9, 2016 Page1 of13 Plan of Correction REBECCA‘S ADULT CARE STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING

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)


November 30, 2016

3Page 3of




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


September 9, 2016

1Page 13of


STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

AGING AND LONG-TERM SUPPORT ADMINISTRATION316 W Boone Ave., Suite 170, Spokane, WA 99201



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)


September 9, 2016

2Page 13of




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.






deficiency.


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.



September 9, 2016

3Page 13of









deficiency.


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.






deficiency.




September 9, 2016

4Page 13of




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.



September 9, 2016

13Page 13of




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.






deficiency.


Documents

AGING AND LONG-TERM SUPPORT ADMINISTRATION · September 9, 2016 Page1 of13 Plan of Correction REBECCA‘S ADULT CARE STATE OF WASHINGTON DEPARTMENT OF SOCIAL AND HEALTH SERVICES AGING