This document w

as prepared by Residential Care Services for the Locator website.

Residential Care Services Investigation Summary Report

Provider/Facility: Clear Choice Adult Family Home LLC(1120336)

Intake ID(s): 3634237

License/Cert. #: AF753526Investigator: Rhodes, Shalahna Region/Unit: RCS Region 2/Unit G InvestigationDate(s):

04/17/201905/03/2019

through

Complainant Contact Date(s): 04/24/2019Allegations:1. The named resident (NR) was fearful of a person in the adult family home (AFH).2. The person would threaten the NR when the NR did not want to eat. saying the NR would not be given medication.3. The NR was kept in the cold and the AFH staff would not turn the heat on.

Investigation Methods:Sample: Residents Observations: Residents, Resident and

Caregiver InteractionsInterviews: Residents, Entity

Representative (ER),Collateral Contact

Record Reviews: Resident Records

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Residential Care Services Investigation Summary Report

Allegation Summary:1. Interview with the NR found the NR did not feel fearful of anyone in the AFH.

Interview with the ER revealed no one had expressed being fearful of anyone in the AFH and if they did, he would talk to them,try to figure out what was wrong, and ty to comfort them,

2. Review of the NR's records found the NR needed assistance with medication.

Interview with the ER revealed the ER wasn't aware of the NR being threatened about medications and eating. The ER statedthat the NR liked to take the medications with ice cream or pudding, which the ER provided. The ER stated that the NR liked totake the medications after the NR ate. The ER also stated that the NR didn't like the food most of the time and often asked forfood the ER didn't have.

Interview with the NR found most of the medications required taking with food.

3. Upon tour of the AFH heat was felt throughout the AFH and could be heard. Observation of the common area and the NR'sroom found extra blankets. Observation of the NR found the NR sitting in the bedroom on the bed with a cover draped over thelegs. The NR also had a short sleeve shirt on.

Interview with the ER revealed the ER kept the temperature in the AFH on 71 degrees. The ER stated that if someone expressedbeing cold the ER would turn the heat up and the ER also had extra blankets for the residents to cover up with.

Interview with the NR found the NR felt cold until recently and the NR had additional blankets the NR could use to warm up.

Interview with a resident in the AFH revealed the resident had not been cold in the home, but if the resident were, the residentwould tell the ER.

Unalleged Violation(s):1. The AFH failed to ensure the negotiated care plans (NCPs) for three residents included documentation explaining the length oftime each resident could be left in the AFH without staff supervision.

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

See statement of deficiency written 05/03/2019.

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This document w

as prepared by Residential Care Services for the Locator website.

Residential Care Services Investigation Summary Report

Provider/Facility: Clear Choice Adult Family Home LLC(1120336)

Intake ID(s): 3638602

License/Cert. #: AF753526Investigator: Rhodes, Shalahna Region/Unit: RCS Region 2/Unit G InvestigationDate(s):

04/17/201905/03/2019

through

Complainant Contact Date(s): 04/17/2019Allegations:1. No one answered two doors at the adult family home (AFH) after the doors of the AFH were knocked on and the AFH wascalled for 10 minutes. Someone was observed pulling up in the driveway of the AFH and when asked how long were theresidents in the AFH left alone, they stated that the car was being moved and when asked again the response was garbage wasbeing taken out. Three residents in the AFH use assistive devices for walking.

Investigation Methods:Sample: Residents Observations: Residents, Resident and

Caregiver InteractionsInterviews: Residents, Entity

Representative (ER)Record Reviews: Resident Records, Safety

Plan

Allegation Summary:1. Upon arrival at the AFH on 04/17/19 Department Staff knocked on two separate doors and called the AFH for 10 minutes withno response before someone was observed pulling into the driveway of the AFH in a minivan. Observation of the AFH on04/17/19 around 8:50 AM showed three residents in the AFH.

Review of a resident's negotiated care plan (NCP) dated 04/05/19 showed the resident used a andcould ambulated for short distances using the . Review of the resident's NCP also showed the resident was at risk for falls.

Review of a second resident's NCP dated 04/15/19 showed the resident could ambulate using a cane for short distances withstandby assistance. Review of the resident's NCP also showed the resident was at risk for falls.

Review of a third resident's NCP dated 03/07/19 showed the resident could ambulate using a for short distances and couldself-propel using a wheelchair. Review of the resident's NCP also showed the resident was at risk for falls.

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as prepared by Residential Care Services for the Locator website.

Residential Care Services Investigation Summary Report

Unalleged Violation(s):Review of the three residents' NCPs on 04/29/19 did not show documentation regarding the length of time the three residentscould be left in the AFH without staff supervision. The three residents were all at risk for falls.

Interview with the ER showed the ER stated they were moving the ER's car when Department Staff arrived. The ER stated therewas a pager system that had a 200 foot range that the ER would use when the ER would leave outside the AFH. The ER stated toa Field Manager (FM) that they were in the backyard taking out the garbage when Department Staff arrived at the AFH. The ERprovided the department with a safety plan dated 04/17/19 on 04/17/19, which showed that the ER or another staff memberwould be with the residents during outside tasks to ensure the safety of the residents at all times.

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

See statement of deficiency written 05/03/2019.

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This document w

as prepared by Residential Care Services for the Locator website.

This document w

as prepared by Residential Care Services for the Locator website.

This document w

as prepared by Residential Care Services for the Locator website.