Access Washington Home...Licensee: ANDRIAN CHAGAY WAC 388-76-10130 Qualifications Provider, entity...

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)


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


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


July 18, 2016

1Page 5of






Julie Miranda, BSN, RN, AFH Licensor

From:




Kent, WA 98032-2388

(253)234-6007




investigation of: 7/8/2016 and 7/18/2016

BENSON HILL AFH

10923 SE 183RD CT

RENTON, WA 98055



enclosed report.








July 18, 2016

2Page 5of




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:


July 18, 2016

3Page 5of




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.


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.



July 18, 2016

4Page 5of









deficiency.


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.


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.



July 18, 2016

5Page 5of









deficiency.



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


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


March 24, 2016

1Page 4of






Louise Zeile, BSN, Complaint Investigator

From:




Kent, WA 98032-2388

(253)234-6007




investigation of: 3/1/2016 and 3/19/2016

BENSON HILL AFH

10923 SE 183RD CT

RENTON, WA 98055



enclosed report.








March 24, 2016

3Page 4of




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.






deficiency.


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 .



March 24, 2016

4Page 4of




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.






deficiency.


Access Washington Home...Licensee: ANDRIAN CHAGAY WAC 388-76-10130 Qualifications Provider, entity...

Documents

Transcript of Access Washington Home...Licensee: ANDRIAN CHAGAY WAC 388-76-10130 Qualifications Provider, entity...