Investigation Summary Report - Washington · The home failed to ensure the named caregiver completed required training prior to providing care (including medication assistance) and/or

Residential Care Services Investigation Summary Report

Provider/Facility: A Golden Road AFH (1053149) Intake ID(s): 3559120

License/Cert. #: AF753384Investigator: Kundur, Melissa Region/Unit: RCS Region 1/Unit A Investigation

Date(s):09/05/201809/27/2018

through

Complainant Contact Date(s): 09/05/2018, 10/02/2018Allegations:#1: A named caregiver gave a named resident medication twice a day as if it were scheduled, but the medicationwas ordered only as needed. The caregiver also nearly gave the resident the wrong dose of medication.#2: A named resident had an unexplained bruise on the top and bottom of one There was concern the resident had beenmistreated.#3: The food was awful.

Investigation Methods:Sample: 5 current residents and

the closed record of thenamed resident

Observations: Sampled residents(including skinobservation), staff-resident interactions,meal observation

Interviews: Sampled residents(including namedresident at current livingsetting), others notassociated with thefacility, caregivers,provider

Record Reviews: Sampled residentrecords, incident log,medication log, personnelrecords, records from thecurrent living setting forthe named resident

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Residential Care Services Investigation Summary Report

Allegation Summary:#1: Medication errors affecting the named resident could not be substantiated. The home failed to ensure medication logs werecomplete and/or included initials of the actual staff providing medication assistance for the named resident, additional sampledresidents, and one supplemental discharged resident. The home failed to ensure the named caregiver completed requiredtraining prior to providing care (including medication assistance) and/or being the only caregiver present in the home. The homefailed to ensure the named caregiver completed background check screening prior to having unsupervised access to residents.The home failed to keep medication orders for the named resident when s/he moved out of the home.#2: Current residents and/or their representatives denied concerns about staff treatment. The home failed to document thenamed resident's foot bruises on the incident log. The named resident was unable to say how the bruises occurred due to his/hercognitive status.#3: The food-related concerns occurred while the caregiver named in allegation #1 was on duty while the provider was out oftown. This caregiver had not completed the required training or a background check. (Refer to allegation #1 above.) Currentresidents and/or their representatives denied concerns about food at the home.Personnel record review showed the home failed to maintain a current background check for the provider. The home failed toensure one other caregiver maintained home care aide certification.

Unalleged Violation(s): Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

See Statement of Deficiencies dated 9/27/18. Citations written under WAC 388-76-10475-2c,2e,3a Medication-Log; WAC 388-76-10220-3 Incident Log; WAC 388-76-10140-2 Qualifications-Students-Volunteers & WAC 388-112A-0080-3,0200-2a,0220-2aResidential Long-Term Care Services Training; WAC 388-76-10161-3 Background Checks-Who Is Required to Have; WAC 388-76-10165-1 Background Checks-Washington State Name and Date of Birth Background Check-Valid for Two Years; WAC 388-76-10135-4 Qualifications-Caregiver & WAC 388-112A-0105-1 Residential Long-Term Care Services Training; and WAC 388-76-10315-1f,g Resident Record-Required.

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Completion DateLicense #: 753384

September 27, 2018

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A Golden Road AFHPlan 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: Bright Hearth LLC

Melissa Kundur, RN, Complaint Investigator

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 complaint

investigation of: 9/5/2018 and 9/27/2018

A Golden Road AFH

2004 E South Ridge Dr

Spokane, WA 99223

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: 3559120

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

DateResidential Care Services

DateProvider (or Representative)


September 27, 2018

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On 09/27/18 at 12:45 PM, Staff C, a caregiver, said Staff A and Staff B went on vacation out of

state for a few days starting on 07/24/18.

On 09/27/18 at 1:05 PM, Staff A and Staff B said they were out of state from 07/24/18 to the

evening of 7/30/18. Staff B said Staff C assisted residents with medications and charted using

Staff B's initials.

Medication log review showed Staff B initialed daily for medications from 07/24/18 to 07/30/18.

This included medications given to Resident #s 1, 2, 3, 4, 6, and 7.

On 09/27/18 at approximately 1:10 PM, Staff C said she saw Staff B's initials on the medication

log and just kept using those initials.

3) Residents, representatives, and/or family members were interviewed about care at the home

and provided the following information:

*On 09/04/18 at 11:06 AM, Resident #6's family member recounted two recent visits to the

home when Staff D, a caregiver, helped the resident with medications.

*On 09/05/18 at 8:57 AM, Resident #2 said Staff D brought medicines to

*On 09/05/18 at 9:15 AM, Resident #4 said Staff D helped with medications.

Medication logs were reviewed for Resident #2, #4, and #6. The logs did not include Staff D's

initials for any medication.

On 09/05/18 at 12:22 AM, Staff A said Staff D helped with medications at the home for several

days. Staff A said Staff D prepared the medications by popping them out of bubble packs, then

gave them to residents. Staff A said he (Staff A) documented on the medication log using his

own initials.

This is a recurring deficiency cited on 12/20/17 and 01/26/18.

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, A Golden Road 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 388-76-10220 Incident log. The adult family home must keep a log of:

(3) Any injury to a resident.

This requirement was not met as evidenced by:


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WAC 388-76-10140 Qualifications Students Volunteers. The adult family home must

ensure that students and volunteers meet the following minimum qualifications:(2) Meet the department's training requirements of chapter 388-112 WAC;

WAC 388-112A-0080 Who is required to complete the seventy-hour long-term care worker

basic training and by when? The following individuals must complete the seventy-hour

long-term care worker basic training unless exempt as described in WAC 388-112A-0090 :

(3) Long-term care workers in adult family homes within one hundred twenty days of date of

hire. Long-term care workers must not provide personal care without direct supervision until

they have completed the seventy-hour long-term care worker basic training.

WAC 388-112A-0200 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.

(2) Long-term care worker orientation. Individuals required to complete the seventy-hour long-

term care worker basic training must complete long-term care worker orientation, which is two

hours of training regarding the long-term care worker's role and applicable terms of employment

as described in WAC 388-112A-0210 .(a) All long-term care workers who are not exempt from certification as described in RCW

18.88B.041 hired on or after January 7, 2012, must complete two hours of long-term care worker

orientation training before providing care to residents.

WAC 388-112A-0220 What is safety training, who must complete it, and when should it be

completed?(2) The following individuals must complete safety training:

(a) All long-term care workers who are not exempt from certification as described in RCW

18.88B.041 hired after January 7, 2012, must complete three hours of safety training. This safety

training must be provided by qualified instructors that meet the requirements in WAC 388-

112A-1260 .

Based on interview and record review, the home failed to ensure one of five caregivers (Staff D)

completed required training prior to providing care and/or being the only caregiver present in the

home. This failure resulted in potential medication errors for Resident #6 and placed all

residents at risk for medication errors and/or unmet care needs.

Findings included:

Residents, representatives, and/or family members were interviewed about care at the home and

provided the following information:

*On 09/04/18 at 11:06 AM, Resident #6's family member said Staff D worked regularly at the

home, including overnights. The family member recounted two recent visits to the home on

different days when Staff D was helping the resident with medications. The family member said

the incorrect medications were in the cup each time, so the family member had Staff D remove

the wrong medications before the resident took them.

*On 09/05/18 at 8:57 AM, Resident #2 identified Staff D as a worker in the home. The resident

said Staff D brought medicines to and helped at night.

*On 09/05/18 at 9:15 AM, Resident #4 said Staff D worked at the home, including helping with



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medications.

*On 09/07/18 at 2:52 PM, Resident #6's representative said Staff D was the caregiver on duty

when Staff A and Staff B went on vacation. The representative said she visited the home one

evening when Staff D was working and no one else was at the home. The representative said

Staff D phoned Staff C, who arrived later at the home.

*On 09/17/18 at 12:52 PM, Resident #2's representative identified Staff D as a caregiver at the

home.

*On 09/17/18 at 12:56 PM, Resident #3's representative identified Staff D as a caregiver at the

home.

*On 09/24/18 at 11:51 AM, Resident #4's family member identified Staff D as a regular

caregiver at the home.

On 09/05/18 at 11:50 AM, Staff A said Staff D was a volunteer and a new worker at the home.

Staff D had been shown around the home but had not provided any care.

On 09/05/18 at 12:10 PM, Staff C, a caregiver, said Staff D worked at the home but on different

shifts.

On 09/05/18 at 12:22 PM, Staff A said Staff D had not completed basic training and/or

orientation/safety training. Staff A said Staff D worked alongside Staff A at the home for only a

couple of days. Staff A acknowledged Staff D had prepared and assisted with medications. Staff

A denied Staff D was ever the only caregiver on duty at the home.






deficiency.


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

(3) All household members over the age of eleven, volunteers, students, and noncaregiving staff

who may have unsupervised access to residents must have a Washington state name and date of

birth background check. They are not required to have a national fingerprint background check.

Based on interview and record review, the home failed to ensure one of one volunteers (Staff D)

completed background check screening prior to having unsupervised access to residents. This

failure placed residents at risk for abuse/neglect by a potentially disqualified person.

Findings included:



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Residents, representatives, and/or family members were interviewed about care at the home and

provided the following information:

*On 09/04/18 at 11:06 AM, Resident #6's family member said Staff D worked alone at the

home, including overnights. The family member recalled a recent visit when she spoke with

Staff D about the resident's medications. The family member said no one else was present with

Staff D.

*On 09/05/18 at 8:57 AM, Resident #2 said Staff D helped at night.

*On 09/07/18 at 2:52 PM, Resident #6's representative said Staff D was the caregiver on duty

when Staff A and Staff B went on vacation. The representative said she visited the home one

evening when Staff D was working and no one else was at the home.

On 09/05/18 at 12:10 PM, Staff C, a caregiver, said Staff D worked at the home but on different

shifts.

On 09/05/18 at 12:22 PM, Staff A said Staff D worked alongside Staff A at the home for only a

couple of days. Staff A said he and Staff D were always together. When asked about the

conversation between Staff D and Resident #6's family member, Staff A said he was unsure

what was said because Staff A was not present. Staff A said he must have been in another room.






deficiency.


WAC 388-76-10165 Background checks Washington state name and date of birth

background check Valid for two years National fingerprint background check Valid

indefinitely.

(1) A Washington state name and date of birth background check is valid for two years from the

initial date it is conducted. The adult family home must ensure:(a) A new DSHS background authorization form is submitted to the department's background

check central unit every two years for each individual listed in WAC 388-76-10161 ;(b) There is a valid Washington state background check for all individuals listed in WAC 388-

76-10161 .

Based on observation, interview, and record review, the home failed to maintain a current

background check for Staff A, the provider. This failure placed residents at risk for receiving

care/services from a disqualified provider.

Findings included:



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During an onsite visit on 09/05/18, Staff A, the provider, was observed to be at the home and

interacting with residents from 8:50 AM to 1:10 PM.

Personnel records were reviewed at the home on 09/05/18. The most current background check

for Staff A was dated 07/22/16.

On 09/05/18 at 12:50 PM, Staff A said he was not aware his background checks had to be done

every two years.






deficiency.


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

caregiver has the following minimum qualifications:(4) Has completed the training requirements in effect on the date the caregiver was hired,

including the requirements applicable to the caregiver under chapter 388-112 WAC;

WAC 388-112A-0105 Who is required to obtain home care aide certification and by when?

Unless exempt under WAC 246-980-070 , the following individuals must be certified by the

department of health as a home care aide within the required time frames:

(1) All long-term care workers, within two hundred days of the date of hire;

Based on observation, interview, and record review, the home failed to ensure one of five

caregivers (Staff B) maintained home care aide certification. This failure resulted in residents

receiving care from an unqualified caregiver.

Findings included:

On 09/05/18 at 8:50 AM, Staff A, the provider, identified Staff B as one of the home's

caregivers.

During an onsite visit on 09/05/18, Staff B was observed to be at the home and providing

intermittent care to residents from 8:50 AM to 1:10 PM. As an example, Staff B assisted

Resident #4 with medications at 9:50 AM.

Per personnel record review, Staff B's home care aide (HCA) credential expired on 08/18/18.



September 27, 2018

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Review of online Department of Health records confirmed Staff B's credential was expired.

On 09/05/18 at 12:50 PM, Staff B and Staff A said they were unaware Staff B's credential had

expired.






deficiency.


WAC 388-76-10315 Resident record Required. The adult family home must:

(1) Create, maintain, and keep records for residents in the home where the resident lives and

ensure that the records:(f) Be kept for three years after the resident leaves the home or death of the resident;

(g) Be available so that department staff may review them when requested; and

Based on interview and record review, the home failed to keep medication orders for one of one

discharged residents (#6). This resulted in missing documentation related to changes in Resident

#6's medication.

Findings included:

Resident #6 moved into the home on /18. A 04/24/18 assessment showed the resident had

significant and experienced The assessment and the 02/16/18

Negotiated Care Plan (NCP) showed the resident required medication assistance. The resident

moved out of the home on /18.

At admission, the resident had physician orders for 130 milligrams (mg; to prevent

twice a day. The August 2018 medication log showed handwritten alterations

indicating a decrease in the resident's morning dose of starting on 08/23/18.

Per record review, the physician orders for the change were not part of the resident's

record.

On 09/05/18 at 12:22 PM, Staff A, the provider, said he sent all physician orders for Resident #6

to the new facility when the resident moved. Staff A said he did not retain any copies.



September 27, 2018

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deficiency.


Investigation Summary Report - Washington · The home failed to ensure the named caregiver completed required training prior to providing care (including medication assistance) and/or

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