AGING AND LONG-TERM SUPPORT ADMINISTRATION · training and long-term care worker orientation training. (1) Facility orientation. Individuals who are exempt from certification described

Completion DateLicense #: 752518

November 2, 2016

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ABC DWELLING ADULT FAMILY HOME LLCPlan 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: ABC DWELLING

Olga Petrov, RN, 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 follow-up inspection

of: 10/14/2016

ABC DWELLING ADULT FAMILY HOME LLC

23821 99TH AVE S

KENT, WA 98031

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: August 12, 2016

The department staff that inspected the adult family home:

DateResidential Care Services

DateProvider (or Representative)


November 2, 2016

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WAC 388-76-10161 Background checks Who is required to have.

(2) The adult family home must ensure that all caregivers, entity representatives, and resident

managers who are employed directly or by contract after January 7, 2012, have the following

background checks:(a) A Washington state name and date of birth background check; and

Based on observation, interview and record review, the adult family home (AFH) failed to

ensure 1 of 1 caregivers (Caregiver E) hired after 01/01/2012, had a background inquiry (BGI).

This failure placed the 4 of 4 residents at risk of harm from a caregiver with an unknown

criminal background.

Findings include:

Observation, interviews and record reviews occurred on 10/14/16 unless otherwise noted.

At 11:20 am, Caregiver B answered the door. Caregiver B said Caregiver E worked day shift on

Sunday.

Observation of Resident #1, 2, 3 and 4 revealed they were cognitively impaired and required

assistance with activities of daily living.

The Entity Representative (ER) was not in the house. Caregiver B called the ER's spouse. In the

phone interview, the ER's spouse who has been acting as a Resident Manager (RM) said he had

Caregiver E's record at his home and agree to fax it to the department.

On 10/17/16, received a copy of Caregiver E's BGI result dated 8/11/16. Under result written as

follow, "Background check could not be completed."

On 10/31/16, the RM said the home re-faxed Caregiver E's BGI application to BGI unit on

8/15/16 and did not receive the result "yet." When asked if the home follow-up with the BGI unit

to obtain Caregiver E's BGI result, the RM said he called "at the end of September and was told

they (BGI) look at her (Caregiver E) file." When asked what the home did to ensure of obtaining

Caregiver E's BGI result, the RM said he "was lost."

On 11/02/16, in communication with the Department background check central unit (BCCU)

showed the home submitted Caregiver E's BGI application. BCCU stated, "we rejected the

background check authorization forms for this applicant (Caregiver E) on 11/01/2016 and

08/18/2016 because the wrong form was used, and on 08/11/2016 and 08/09/2016 because the

account number used (Box #4) was incorrect and fields in box #10 were left blank."

The ER did not obtain Caregiver E BGI result before allowing the caregiver unsupervised access

to residents.

This requirement was not met as evidenced by:


November 2, 2016

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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, ABC DWELLING ADULT FAMILY

HOME LLC 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: ABC DWELLING ADULT FAMILY HOMELLC (790014)

Intake ID(s): 3235442

License/Cert. #: AF752518Investigator: Kim, Dahl Region/Unit: RCS Region 2/Unit F Investigation

Date(s):08/02/201608/12/2016

through

Complainant Contact Date(s): 08/01/2016, 08/15/2016, 08/16/2016Allegations:Named resident was taken to the emergency and found with multiple pressure sores in multiple areas of body. The homereported the resident was on comfort measures only.

Investigation Methods:Sample: 2 current and 1 former

residentsObservations: General care, resident

hygiene, resident-staffinteractions, staffing andstaff availability

Interviews: Resident, staff,professional not affiliatedwith the home

Record Reviews: Resident records,incident log, staff records

Allegation Summary:Observation found residents were clean and groomed. Observed resident-staff interactions were respectful. The home was cleanand did not have odor. On interview, one resident stated there were two caregivers working at all times. The named resident nolonger resided at the home. The resident assessment revealed the named resident did not have pressure sores at the time ofthe admission to the home. When the named resident developed a pressure sore, the entity representative's husband who is aregistered nurse reported it to the resident's PCP and family. When interviewed he stated the named resident was in a

at the time of the admission. He said he was working with a wound nurse who was coming in to the home 2-3times a week. When interviewed Staff A said he did not see pressure sores, as the sores were covered with dressing and theentity representative's husband changed the dressing. When interviewed two caregivers stated they repositioned the namedresident every 2-3 hours. The home had a document indicating the named resident was on comfort measures only. Investigationfound no evidence suggesting the home did not follow the named resident's negotiated care plan.

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Residential Care Services Investigation Summary Report

Unalleged Violation(s):One caregiver did not have orientation prior to interacting with residents.One caregiver did not have a valid first aid card.Entity representative did not submit a background check for one caregiver.One caregiver did not have tuberculosis screening within three days of employment.One former resident's negotiated care plan was not agreed to and signed/dated by the resident/resident's representative.Admission agreement and house policies were not provided to two residents.One former resident's personal belongings list was not signed or dated.One caregiver performed insulin injections to one resident without nurse delegation.Entity representative did not report to the Department case manager when one former resident had a significant change in hiscondition and was transferred to hospital.

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

WAC 388-76-10135(4)/WAC 388-112-0015(4): One caregiver did not have orientation prior to interacting with residents.WAC 388-76-10135(7)/388-112-0260(1)(c)(ii): One caregiver did not have a valid first aid card.WAC 388-76-10163(2): Entity representative did not submit a background check for one caregiverWAC 388-76-10265(1)(d): One caregiver did not have tuberculosis screening within three days of employment.WAC 388-76-10375(1): One former resident's negotiated care plan was not agreed to and signed and dated by theresident/resident's representative.WAC 388-76-10530: Admission agreement and house policies were not provided to two residents.WAC 388-76-10320(10): One former resident's personal belongings list was not signed or dated.WAC 388-76-10400(4)/10455(2): One caregiver performed insulin injections without nurse delegation.WAC 388-76-10225(2)(f): Entity representative did not report to the Department case manager when one former resident had asignificant change

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August 12, 2016

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STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

AGING AND LONG-TERM SUPPORT ADMINISTRATION20425 72nd Avenue S, Suite 400, Kent, WA 98032-2388



Dahl Kim , Field Manager

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: 8/2/2016, 8/5/2016 and 8/12/2016

ABC DWELLING ADULT FAMILY HOME LLC

23821 99TH AVE S

KENT, WA 98031

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: 3235442

The department staff that inspected and investigated the adult family home:

DateResidential Care Services

DateProvider (or Representative)


August 12, 2016

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WAC 388-76-10135 Qualifications Caregiver. The adult family home must ensure each

caregiver has the following minimum qualifications:(4) Completion of the training requirements that were in effect on the date they were hired

including requirements described in chapter 388-112 WAC;

WAC 388-112-0015 What is orientation training, who should complete it, and when

should it be completed? There are two types of orientation training - Facility orientation

training and long-term care worker orientation training.

(1) Facility orientation. Individuals who are exempt from certification described in RCW

18.88B.041 and volunteers are required to complete facility orientation training before having

routine interaction with residents. This training provides basic introductory information

appropriate to the residential care setting and population served. The department does not

approve this specific orientation program, materials, or trainers. No test is required for this

Based on interview and record review, the entity representative failed to ensure 1 of 5 caregivers

(Staff E) completed facility orientation training before having routine interactions with residents.

This failure placed residents at risk of unmet care needs. Findings include:

All observation, interview and record review occurred on 8/2/16 unless otherwise indicated.

Upon arrival at the home Staff A and E were observed with five residents. The entity

representative (ER) was not in the home. When asked Staff E said she began working on

7/10/16. She said she usually works 2 days a week on Sundays and Mondays from 8 am to 8 pm.

Record review revealed Staff E only had a copy of CPR training and Nursing Assistant

Certification (NAC), Department of Health credential. There was no evidence that Staff E

received orientation training.

When interviewed, the ER's spouse who has been acting as a resident care manager said Staff E

started a couple of weeks ago. He acknowledged Staff E did not have the required orientation.










August 12, 2016

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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

WAC 388-112-0260 What are the CPR and first-aid training requirements?

(1) Adult family homes

(c) Adult family home long-term care workers must obtain and maintain a valid CPR and first-

aid card or certificate:(ii) Before providing care for residents, if the provision of care for residents is not directly

supervised by a fully qualified long-term care worker who has a valid first-aid and CPR card or

certificate.

Based on observation, interview and record review, the entity representative failed to ensure 1 of

5 caregivers (Staff E) had a valid first aid card. This failure placed residents at risk of receiving

inappropriate first aid. Findings include:






Certification (NAC), Department of Health credential. There was no evidence that Staff E had a

valid first aid card.

Later in the day Staff E was not seen in the home. When asked Staff A stated Staff E took a

resident to an appointment.

When interviewed, the ER's spouse who has been acting as a resident care manager

acknowledged Staff E did not have a valid first aid card.

When interviewed on 8/5/16, the ER said Staff E should have a valid first aid card at the hospital

where she also worked.



August 12, 2016

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WAC 388-76-10163 Background checks Process Background authorization form. Before

the adult family home employs, directly or by contract, a resident manager, entity

representative, caregiver, or noncaregiving staff, or accepts as a caregiver any volunteer or

student, or allows a household member over the age of eleven unsupervised access to

residents, the home must:(2) Submit form to the department's background check central unit, including any additional

documentation and information requested by the department.

Based on observation, interview and record review, the entity representative failed to submit 1 of

5 caregivers' (Staff E) the Department background check authorization form to the Department's

background check central unit. This failure placed residents at risk of cared for by an individual

without background check. Findings include:






Certification (NAC), Department of Health credential. There was no evidence of background

check on Staff E.

When interviewed, the ER's spouse who has been acting as a resident care manager said Staff E

completed the background authorization form, but the form has not been submitted.

When interviewed on 8/5/16, the ER said Staff E should have a background check at the hospital




August 12, 2016

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WAC 388-76-10225 Reporting requirement.

(2) When there is a significant change in a resident's condition, or a serious injury, trauma, or

death of a resident, the adult family home must immediately notify:(f) The resident's case manager if the resident is a department client.

Based on interview and record review, the entity representative failed to report to the resident's

Department case manager when one former resident (FR #1) had a significant change in

condition. This failure prevented the Department case manager from providing timely

intervention per their skin protocol. Findings include:


Both the provider and her spouse are registered nurses.


representative (ER) was not at the home. When interviewed, the ER's spouse said he's been

acting as a resident care manager for some time since the ER had an injury in October 2015. On

8/5/16 Staff A and B were observed working at the home.

Record review revealed FR #1 was admitted to the home on /16 with diagnoses including

. FR #1 received case management services from the Department. FR #1's CARE

assessment dated 8/10/15 revealed the resident needed total assistance with activities of daily

living, including transfer and toileting. The assessment indicated the resident's skin was "intact

over all pressure points."

FR #1 was transferred to a hospital on 16 and did not return to the home. A report from the

hospital emergency dated /16 indicated FR #1 was "completely contractured with bed sores

in multiple areas of body... The worse bed sore is on area, approx. the size of a

baseball that has yellow gray drainage coming out of it, extremely foul odor present..."

Record review revealed Staff A completed a resident injury report on 5/8/16 indicating FR #1's

"skin wounds seen in the ." The report stated Staff B witnessed the skin and it was

reported to the resident manager. On 5/8/16 the ER's spouse wrote a progress note indicating FR

#1's "skin over the became black. Concerto Health contacted & informed of request for



August 12, 2016

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WAC 388-76-10265 Tuberculosis Testing Required.

(1) The adult family home must develop and implement a system to ensure the following

persons have tuberculosis testing within three days of employment:(d) Caregiver;

Based on interview and record review, the entity representative failed to ensure 1 of 5 caregivers

(Staff E) had tuberculosis (TB) screening within three days of employment. This failure placed

residents at risk of exposure to contagious disease. Findings include:

All interview and record review occurred on 8/2/16 unless otherwise indicated.





Certification (NAC), Department of Health credential. There was no evidence of Staff E's TB

screening within three days of employment.

When interviewed, the ER's spouse who has been acting as a resident care manager

acknowledged Staff E did not have TB testing.

When interviewed on 8/5/16, the ER said Staff E should have had TB testing at the hospital










WAC 388-76-10320 Resident record Content. The adult family home must ensure that

each resident record contains, at a minimum, the following information:(10) A current inventory of the resident's personal belongings dated and signed by:

(a) The resident; and

(b) The adult family home.

Based on interview and record review, the entity representative failed to have 1 former resident

(FR #1)'s list of personal belongings signed and dated by the resident/resident's representative



August 12, 2016

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#1's assessment and negotiated care plan were dated 1/26/16 and signed by the ER's spouse. It

was not signed or dated by the resident or POA. The ER's spouse updated the assessment and

negotiated care plan on 5/9/16, but again no signature of the resident or resident's representative.

At the exit interview, the ER's spouse was informed of this deficiency.








WAC 388-76-10400 Care and services. The adult family home must ensure each resident

receives:(4) Services by the appropriate professionals based upon the resident's assessment and

negotiated care plan, including nurse delegation if needed.

WAC 388-76-10455 Medication Administration. For residents assessed with requiring the

administration of medications, the adult family home must ensure medication

administration is:

(2) By nurse delegation per WAC 246-840-910 through 246-840-970 ; unless

Based on interview and record review, the entity representative failed to ensure 1 of 5 residents

(Resident #5) received medication administration by either the appropriate professional or nurse

delegation based on the resident assessment. Staff E who was not an appropriate medical

professional performed insulin injection for Resident #5 without nurse delegation. This failure

placed the resident at risk of medication errors. Findings include:

All interview and record review occurred on 8/2/16 unless otherwise indicated.

Both the provider and her spouse are registered nurses.


representative (ER) was not at the home. When interviewed, the ER's spouse said he's been

acting as a resident care manager for some time.

When interviewed Resident #5 said Staff A, B and E gave . said Staff E

gave yesterday and today. The CARE assessment dated 5/31/16 indicated

the resident was always able to supervise caregivers.


Documents

AGING AND LONG-TERM SUPPORT ADMINISTRATION · training and long-term care worker orientation training. (1) Facility orientation. Individuals who are exempt from certification described