residential care services...pharmacy orders/delivery receipts allegation summary: 1) interview with...

Residential Care Services Investigation Summary Report

Provider/Facility: Abundant Living Adult Family Care(862326)

Intake ID(s): 3327009

License/Cert. #: AF752726Investigator: Bolo, Toni Region/Unit: RCS Region 2/Unit B Investigation

Date(s):03/29/201705/22/2017

through

Complainant Contact Date(s): 03/29/2017Allegations:1. The named resident's as needed medication ran out because it was not ordered.

Investigation Methods:Sample: Six residents Observations: Exterior/interior

environment, staff toresident interactions,resident to staffinteractions, residentmovement in facility,medicationstorage/organization

Interviews: Residents, familymembers and staff

Record Reviews: Resident records,progress notes, medicalrecords, facilitypolicies/records,medicationadministration records,pharmacy orders/deliveryreceipts

Allegation Summary:1) Interview with pharmacy staff and record review of pharmacy delivery receipts revealed the named resident's medication wasordered and was delivered to the adult family home when the pharmacy received more stock of the medication. No failedProvider practice identified.

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Unalleged Violation(s):WAC 388-76-10630Resident rights-Quality of life Adult family home response to issues.

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

WAC 388-76-10630 Resident rights-Quality of life Adult family home response to issues.

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Date(s):03/29/201705/22/2017

through

Complainant Contact Date(s): 03/29/2017Allegations:1. The adult family home (AFH) did not know when to contact emergency medical services (EMS).2. The named resident's prescribed diet was not being followed.3. The named resident's pull ups was not being changed.4. The AFH was unable to shower the named resident after 7:00AM.





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Allegation Summary:1. Interviews revealed the AFH staff responded appropriately to situations requiring EMS transport. Record review showed theAFH had a policy of when to contact EMS.2. Record review showed documentation of the named resident's daily meals.3. Observations and interview with the AFH residents on three unannounced Department visits revealed no soiled pull ups.4. Interview with residents and family exposed no concerns with the AFH staff's ability to perform showers for the residents asoutlined in their plan of care. Record review of the named resident's plan of care showed no specified time of day for his/hershower.


Yes No

Conclusion /Action:




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Date(s):03/29/201705/22/2017

through

Complainant Contact Date(s): 03/29/2017Allegations:1. The named resident was discharged inappropriately from the adult family home (AFH).2. The named resident was given his/her medication while flat in bed.3. The named resident's diet was not adequate.4. The AFH cannot evacuate all the residents with one caregiver.5. The named resident is not being changed.6. The AFH residents did not have call buttons.


environment, staff toresident interactions,resident to staffinteractions, residentmovement in facility,medication assistance,evacuation drill

Interviews: Residents, family andstaff


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Date(s):03/29/201705/22/2017

through

Complainant Contact Date(s): 03/29/2017, 03/30/2017, 04/21/2017, 04/25/2017Allegations:1. The named resident was not readmitted to the adult family home (AFH).2. The named resident was dumped at the hospital because he/she was a Medicaid resident.3. The AFH was quitting their Medicaid contract.4. The AFH did not give the named resident a written 30 day notice.





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Allegation Summary:1. Record review of the named resident's hospital discharge orders showed the named resident required skilled nursing care fordaily subcutaneous injections and daily skilled physical therapy.2. Record review and interview revealed the named resident's hospitalization was necessary for his/her health. The namedresident exhibited shortness of breath, was brought to the emergency department by his/her and admitted to thehospital.3. No evidence of the AFH Provider's desire to terminate their Medicaid contract.4. Interview with the named resident's family revealed no verbal or written confirmation of the AFH Provider's desire todischarge the named resident. Interview with hospital discharge planner and AFH Provider revealed the AFH required anassessment of the named resident and a consult for dietary training prior to the named resident returning to the home to ensurethe AFH can meet his/her care and dietary needs.


Yes No

Conclusion /Action:




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Date(s):03/29/201705/22/2017

through

Complainant Contact Date(s): 03/30/2017, 03/31/2017, 04/21/2017, 04/25/2017Allegations:1. The adult family home (AFH) did not give the named resident or his/her family a 30 day notice for discharge.2. The AFH asked family to buy gloves and fruit for the named resident.3. The AFH ran out of medications for the named resident.4. The AFH residents all got urinary tract infections because of not being changed or toileted.5. The AFH woke the named resident up for showers, could not give his/her shower after 7:00AM and asked his/her family toperform his/her shower because staff didn't have time.6. The AFH Provider stopped their Medicaid contract.7. The AFH Provider collected and cashed 10 months worth of the named resident's rent checks at once.





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Allegation Summary:1. Interview with the named resident's family revealed no verbal or written confirmation of the AFH Provider's desire todischarge the named resident. Interview with hospital discharge planner and AFH Provider revealed the AFH required anassessment of the named resident and a consult for dietary training prior to the named resident returning to the home to ensurethe AFH can meet his/her care and dietary needs.2. Interview with residents and family exposed no concerns with the AFH having supplies and fruit.3. Interview with pharmacy staff and record review of pharmacy delivery receipts revealed the named resident's medicationswere ordered and was delivered to the adult family home. Routine medications were delivered automatically every month.4. Observations and interview with the AFH residents on three unannounced Department visits revealed no soiled pull ups. AFHstaff was observed assisting two sampled residents with toileting.5. Interview with residents and family exposed no concerns with the AFH staff's ability to perform showers for the residents asoutlined in their plan of care. Record review of the named resident's plan of care showed no specified time of day for his/hershower.6. No evidence of AFH Provider's desire to terminate their Medicaid contract.7. Reviewed AFH Washington Administrative Code and AFH admission agreement. No failed Provider practice identified.


Yes No

Conclusion /Action:




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Date(s):03/29/201705/22/2017

through

Complainant Contact Date(s): 04/04/2017, 04/21/2017Allegations:1. The named resident was unlawfully discharged.2. The adult family home (AFH) failed to provide a 30 day notice.3. The named resident was dumped at the hospital because of Medicaid discrimination.4. The AFH did not provide low sodium diets or appropriate choices.5. The AFH was not consistent with toileting or changing wet briefs and caused the named resident to get a urinary tractinfection.6. The AFH failed to monitor the oxygen levels of the named resident as prescribed by his/her doctor.7. The AFH woke the named resident up for showers, could not give showers after 7:00AM and asked family to perform showersbecause the AFH staff could not do it after 7:00AM.





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Allegation Summary:1. Record review and interview revealed the named resident's hospitalization was necessary for his/her health. The namedresident exhibited shortness of breath, was brought to the emergency department by his/her daughter and admitted to thehospital.2. Interview with the named resident's family revealed no verbal or written confirmation of the AFH Provider's desire todischarge the named resident. Interview with hospital discharge planner and AFH Provider revealed the AFH required anassessment of the named resident and a consult for dietary training prior to the named resident returning to the home to ensurethe AFH can meet his/her care and dietary needs.3. Record review and interview revealed the named resident's hospitalization was necessary for his/her health. The namedresident exhibited shortness of breath, was brought to the emergency department by his/her and admitted to thehospital.4. Record review showed documentation of the named resident's daily meals and copies of hospital low salt dietinstructions/guidelines for AFH staff reference use.5. Observations and interview with the AFH residents on three unannounced Department visits revealed no soiled pull ups. AFHstaff was observed assisting two sampled residents with toileting.6. Record review showed documentation of the named resident's levels as prescribed by his/her doctor.7. Interview with residents and family exposed no concerns with the AFH staff's ability to perform showers for the residents asoutlined in their plan of care. Record review of the named resident's plan of care showed no specified time of day for his/hershower.


Yes No

Conclusion /Action:




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Date(s):03/29/201705/22/2017

through

Complainant Contact Date(s): 04/04/2017Allegations:1. The adult family home (AFH) discharged the named resident and would not allow him/her to return to the AFH.





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Allegation Summary:1. Record review and interview revealed the named resident's hospitalization was necessary for his/her health. The namedresident exhibited shortness of breath, was brought to the emergency department by his/her and admitted to thehospital.

Interview with the named resident's family revealed no verbal or written confirmation of the AFH Provider's desire to dischargethe named resident.

Interview with hospital discharge planner and AFH Provider revealed the AFH required an assessment of the named resident anda consult for dietary training prior to the named resident returning to the home to ensure the AFH can meet his/her care anddietary needs.


Yes No

Conclusion /Action:



WAC 388-76-10630Resident rights-Quality of life Adult family home response to issues.

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