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Completion DateLicense #: 752518
November 2, 2016
1Page 3of
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)
Completion DateLicense #: 752518
November 2, 2016
2Page 3of
ABC DWELLING ADULT FAMILY HOME LLCPlan of Correction
Statement of Deficiencies
Licensee: ABC DWELLING
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:
Completion DateLicense #: 752518
November 2, 2016
3Page 3of
ABC DWELLING ADULT FAMILY HOME LLCPlan of Correction
Statement of Deficiencies
Licensee: ABC DWELLING
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.
Page 1 of 2
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
Page 2 of 2
Completion DateLicense #: 752518
August 12, 2016
1Page 11of
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
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)
Completion DateLicense #: 752518
August 12, 2016
2Page 11of
ABC DWELLING ADULT FAMILY HOME LLCPlan of Correction
Statement of Deficiencies
Licensee: ABC DWELLING
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.
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
This requirement was not met as evidenced by:
Completion DateLicense #: 752518
August 12, 2016
3Page 11of
ABC DWELLING ADULT FAMILY HOME LLCPlan of Correction
Statement of Deficiencies
Licensee: ABC DWELLING
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:
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 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.
This requirement was not met as evidenced by:
Completion DateLicense #: 752518
August 12, 2016
4Page 11of
ABC DWELLING ADULT FAMILY HOME LLCPlan of Correction
Statement of Deficiencies
Licensee: ABC DWELLING
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
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:
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 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
where she also worked.
This requirement was not met as evidenced by:
Completion DateLicense #: 752518
August 12, 2016
5Page 11of
ABC DWELLING ADULT FAMILY HOME LLCPlan of Correction
Statement of Deficiencies
Licensee: ABC DWELLING
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
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:
All observation, interview and record review occurred on 8/2/16 unless otherwise indicated.
Both the provider and her spouse are registered nurses.
Upon arrival at the home Staff A and E were observed with five residents. The entity
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
This requirement was not met as evidenced by:
Completion DateLicense #: 752518
August 12, 2016
7Page 11of
ABC DWELLING ADULT FAMILY HOME LLCPlan of Correction
Statement of Deficiencies
Licensee: ABC DWELLING
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.
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 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
where she also worked.
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
This requirement was not met as evidenced by:
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
This requirement was not met as evidenced by:
Completion DateLicense #: 752518
August 12, 2016
9Page 11of
ABC DWELLING ADULT FAMILY HOME LLCPlan of Correction
Statement of Deficiencies
Licensee: ABC DWELLING
#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.
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
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.
Upon arrival at the home Staff A and E were observed with five residents. The entity
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.
This requirement was not met as evidenced by: