investigation summary report - washington · investigation summary report ... allegation summary:...

Residential Care Services Investigation Summary Report

Provider/Facility: Norflor Manor, AFH (689212) Intake ID(s): 3196352

License/Cert. #: AF752060Investigator: Corey, Candace Region/Unit: RCS Region 3/Unit C Investigation

Date(s):03/24/201606/20/2016

through

Complainant Contact Date(s):Allegations:Neglect and Unqualified Caregivers

Investigation Methods:Sample: Named resident and two

current residents. Thenamed resident passedaway on 16.

Observations: Residents, environmentand staff interaction withresidents, staff providedcare and services.

Interviews: Resident, staff members,and collateral contacts.

Record Reviews: Sampled residentsrecords, employeerecords and incidentreports.

Allegation Summary:Conducted an on-site investigation related to all allegations and/or incidents identified in the intake. Failed practice identified inthe ability to provide care and services. See Statement of Deficiencies dated 09/13/2016.

Unalleged Violation(s):Deficiencies not related to the original complaint were cited related to licensing requirements, background checks, reportingrequirements, specialty training, tuberculosis testing. See statement of Deficiencies 09/13/2016 for further information.

Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

Failed provider practice identified:WAC 388-76-10035(5) License requirementsWAC 388-76-10670 (2) Prevention of abuseWAC 388-78-10180 Background checks. Disqualifying informationWAC 388-76-10181 Background checks. Non disqualifying informationWAC 388-76-10225(1)(b)(I)(ii)(iii) Reporting requirements

of 2

Residential Care Services Investigation Summary Report

WAC 388-76-10285 Tuberculosis. Two step skin testingWAC 388-112-0165 Who is required to complete specialty training and whenSee Statement of Deficiencies dated 09/13/2016

of 2

Completion DateLicense #: 752060

June 23, 2016

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Norflor Manor, AFHPlan of Correction

STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

AGING AND LONG-TERM SUPPORT ADMINISTRATIONPO Box 45819, Olympia, WA 98504-5819

Statement of Deficiencies

Licensee: NORMA AND

Candace Corey, RN,BSN , Complaint Investigator

From:

DSHS, Aging and Long-Term Support Administration

Residential Care Services, Region 3, Unit D

PO Box 45819

Olympia, WA 98504-5819

(360)664-8421

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: 3/24/2016 and 6/20/2016

Norflor Manor, AFH

514 Trailblazer Ct SE

Lacey, WA 98503

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: 3196352

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

DateResidential Care Services

DateProvider (or Representative)


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described the injury as a

A second incident occurred at the same home involving another resident who fell in the kitchen

hitting and required transport via ambulance to the hospital for evaluation and

treatment.

When asked about the lack of reporting (WAC 388-76-10225 Reporting Requirement

(1)(b)(i)(ii)(iii) the provider stated she did not contact the 1-800 hot line to report residents'

accidents/injuries as required under WAC 388-76-10225 (1)(b)(i)(ii)(2)(a)(b)(c) she contacted

"911" instead.

These actions by the provider at one of three homes represented a lack of understanding to meet

the needs of the residents.

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, Norflor Manor, 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 388-76-10035 License requirements Multiple family home providers. The

department will only consider an application for more than one home if the applicant has:(5) An entity representative or a resident manager at each home who is responsible for the care

of each resident at all times.

Based on interview and record review the provider failed to ensure one of three adult family

homes owned and operated by the same provider ( Norflor Manor, AFH ) had a resident

manager who maintained oversite of the home and the residents who lived in the home. This

failure resulted in residents not having the benefit of a resident manager who was able to make

daily decisions regarding the operation of the home and their care.

Findings include:

Interview and record review took place on 5/11/16 unless otherwise noted.

The adult family home was licensed 10/3/2011 with a capacity of 5 residents . The home has

specialties of and allowing them to admit and care for residents with

those diagnoses.

The resident manager of record was Resident Manager #1/Caregiver#1. Her date of hire as a

caregiver was 3/3/2010. According to the employee record the she was hired as an adult family

This requirement was not met as evidenced by:


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home resident manager on 5/11/11.

Her last day she worked at the home as Resident Manager of the home was estimated by the

provider to be 1/31/16.

During interview on 5/11/16 when asked about the resident manager's work history at the home,

the provider stated the resident manager was on bereavement leave in January 2016 due to the

death of her grandmother in Samoa and had returned to Samoa to assist and support her family.

The provider stated she received the last text message from the resident manager on 3/10/16 and

she never returned to work.

Caregiver #2 stated the resident manager left her job at the adult family home sometime in

January 2016 to assist her family in Samoa when her grandmother passed away. Caregiver #2

stated the resident manager did not return to her job at the adult family home after leaving to go

to Samoa.

The resident manager has not been reachable by phone.

During a visit to the adult family home on 3/25/16 the caregiver on duty stated she did not know

who the resident manager was for the home.

Based on the information received during interviews with the provider and caregivers there has

not been a resident manager from 1/ (exact day unknown)/2016 to current.

During a 5/11/16 interview the Provider stated her spouse's eldest son would complete his

training on 5/18/2016 and take over the role of resident manager for the home.

No request for a change of resident manager was received in this office to date. There is no

resident manager of record in the home at this time.






deficiency.


WAC 388-76-10180 Background checks Employment Disqualifying information.

[Disqualifying negative actions.](1) The adult family home must not employ, directly or by contract, a caregiver, entity

representative, or resident manager if:


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(a) The caregiver, entity representative or resident manager will have unsupervised access to

vulnerable adults, as defined in RCW 43.43.830 ; and either:(b) The caregiver, entity representative or resident manager has a disqualifying criminal

conviction or pending charge for a disqualifying crime under chapter 388-113 WAC; or

Based on interview and record review the provider hired a caregiver (Caregiver #6) with a

disqualifying crime. This action placed residents at risk for being cared for by a caregiver whose

background check disqualified her and would not allow her to care for vulnerable adults/persons.

Interview and record review took place on 5/11/16 unless otherwise noted.

Caregiver #6 was hired on 11/25/15 by the provider as a caregiver at Norflor Manor AFH.

Caregiver #6 provided unsupervised care to between two and five vulnerable adults. Caregiver

#6 last day of employment was the end of March 2016.

Review of Caregiver #6's record revealed three completed criminal background checks dated

12/4/15, 12/ 7/15, and 1/19/16. Each of the completed criminal background checks indicated

Caregiver #6 had a disqualifying crime in/on 7/2/2013 as well as abuse of a vulnerable person.

In an interview with the provider, when asked why she hired Caregiver #6 with a clearly

disqualifying crime and maintained her employment in an unsupervised setting caring for

vulnerable adults for 4 months, she responded she wanted to give the caregiver a chance to have

her crime expunged from her record.






deficiency.



WAC 388-76-10181 Background checks Employment Nondisqualifying information.

(1) If any background check results show that an employee or prospective employee has a

criminal conviction or pending charge for a crime that is not disqualifying under chapter 388-

113 WAC, then the adult family home must:(a) Determine whether the person has the character, competence and suitability to work with

vulnerable adults in long-term care; and(b) Document in writing the basis for making the decision, and make it available to the

department upon request.


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Licensee: NORMA AND

Based on record review the provider failed to complete a Character, Competency and Suitability

(CCS) review for 2 of 9 caregivers (Caregiver #5 and the Former Resident Manager) based on a

background check utilizing fingerprints and identifying negative findings. This failure resulted

in the residents being cared for by a caregiver and the former resident manager who's Character,

Competency and Suitability was not determined.

Findings include:

Record review took place on 5/25/16 unless otherwise noted.

The Former Resident Manager's criminal background check completed with fingerprints was

completed 11/15/13 and expired 11/15/15. The negative action requiring a CCS review and

documentation of completion of the task was required based on action dated 5/19/2010 and

11/29/2010. No CCS documentation of a CCS could be found in the former resident manager's

employee record.

Review of Caregiver #5's employee record revealed it did not contain a CCS review. The CCS

review was required due to negative action occuring in 1997, 1999, 2005 and 2010.

During interview on 6/20/16 the provider stated she was sure she had completed the CCS's on

the caregiver and the former resident manager. The provider stated she left much of the filing of

documents to the former resident manager and did not realize how much was missing from the

records until she recently checked them.






deficiency.



WAC 388-76-10225 Reporting requirement.

(1) The adult family home must ensure all staff:

(b) Report the following to the department by calling the complaint toll-free hotline number:

(i) Any actual or potential event requiring any resident to be evacuated;

(ii) Conditions that threaten the provider's or entity representative's ability to continue to provide

care or services to each resident; and(iii) A missing resident.

Based on record review and interview the provider failed to ensure unwittenessed falls with



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injuries for 2 of 3 residents (Resident #1 and Former Resident #2) were reported to the

Department on the 1-800 hot line . This failure resulted in the inability of the Department to

investigate the circumstance surrounding the falls and for the adult family home to identify

accident trends in the home and aid in prevention of further occurrences.

Findings include:

Record review and interview took place on 5/11/16 unless otherwise noted.

Review of Resident #1's record revealed documentation of a fall type accident on 13

requiring "911" be called and the resident was transported via ambulance to St Peter's Hospital

for evaluation. A scan was completed and Resident #1 was kept in the hospital overnight for

observation with a diagnosis of .Caregiver notes stated the resident had a"

Review of Resident #1's accident/injury/incident log revealed an accident occurred on 4/25/15

without identified injury. Another fall with injury occurred on 2/23/16 in the hall while being

transferred at which time Resident #1 sustained rug burns to the and of the

and bruises to the . Caregiver notes identify falls involving Resident #1 with

minor injury that were treated with first aid at the adult family home.

Record review documented Former Resident #2 fell in the kitchen injuring the of on

the kitchen cupboard. was sent to the hospital via ambulance.

None of the unwitnessed falls with injuries were reported by the facility to the Department on

the 1-800 hot line number.

On 6/24/16 during a phone interview the provider stated "All the years I've been doing this

(business) I have never called the 1-800 number". When asked when she or caregivers would

call the 1-800 number the provider stated "Anytime abuse or see something that's not right

occurs." I ask them (caregivers/staff) to come to me first, it may be a misunderstanding. The

provider went on to say she was unaware she needed to call the 1-800 DSHS hot line if an

unwittnessed fall with injuries occurred and the resident could not tell what happened.






deficiency.



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Licensee: NORMA AND

WAC 388-76-10285 Tuberculosis Two step skin testing. Unless the person meets the

requirement for having no skin testing or only one test, the adult family home, choosing to

do skin testing, must ensure that each person has the following two-step skin testing:

(1) An initial skin test within three days of employment; and

(2) A second test done one to three weeks after the first test.

Based on record review and interview the provider failed to ensure 3 of 9 caregivers (Caregiver

#4, #5 and #9) completed the required tuberculosis screenings. This failure resulted in residents

being cared for by caregivers whose tuberculosis status could not be determined.

Findings include:

Record review took place on 5/11/16 unless otherwise noted.

Review of Caregiver #4's employee record documented she completed a two -step tuberculosis

screening in May 2015, however she did not have the required initial one step within 3 days of

her hire date of 6/15/15.

On 6/20/16 the provider stated she thought the caregiver had the required TB test.

Caregiver #5's date of hire was 6/14/15. Review of Caregiver #5's record documented an initial

tuberculosis screening completed on 6/13/15 with no reading of the results. On 8/18/15 a

second screening was completed with a negative reading on 8/20/15. Based on the information

in her record Caregiver #5 had neither a initial tuberculosis screening within 3 days of hire or a

completed two step within 21 days of hire.

During interview on 6/20/16 the provider stated the caregiver told her she had the two step

testing completed, however she did not have it completed. The caregiver had a TB screening

prior to being hired that was not read and could not be used to verify tuberculosis status. The

provider stated she had the caregiver start over and then she quit.

Caregiver #9 had a date of hire listed as 12/23/15. Record review indicated she had an initial

tuberculosis screening on 12/25/15 with a negative result. The caregiver had a second screening

on 1/13/16, however that tuberculosis screening was not read and there were no results listed.

Caregiver #9 did not have documentation of the required two step screening in her employee

record.

During interview on 6/20/16 the provider stated she did not recall about the 2nd tuberculosis test

not being read. She stated she thought it was completed and read. The provider stated she

usually did an every three month review of records and would catch the missing documents.



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deficiency.


WAC 388-76-10670 Prevention of abuse. The adult family home must:

(2) Ensure each resident's right to be free from abandonment, verbal, sexual, physical and mental

abuse, exploitation, financial exploitation, neglect, and involuntary seclusion;

Definition of Neglect. "Neglect" means: (1) A pattern of conduct or inaction by a person or

entity with a duty of care that fails to provide the goods and services that maintain physical or

mental health of a vulnerable adult, or that fails to avoid or prevent physical or mental harm or

pain to a vulnerable adult; or (2) An act or omission that demonstrates a serious disregard of

consequences of such a magnitude as to constitute a clear and present danger to the vulnerable

adult's health, welfare, or safety, including but not limited to conduct prohibited under

RCW9A.42.100.

Based on record review and interview the provider failed to protect one of three residents from

neglect (Resident #1). This failure resulted in the resident developing a wound (pressure ulcer)

on and that without adequate intervention eventually progressed to a stage 4

decubitus ulcer that could not be healed. In addition the provider failed to follow physician's

orders to report blood pressures and weights of (Resident #1), failed to report to Resident #1's

physician and family weight loss and the initial development and progress of the

aforementioned wound in a timely manner and the provider failed to personally, visually and

tactically assess and monitor Residen#1's wound. This failure resulted in the resident not

receiving the appropriate care for wound.

Findings include:

Resident #1 was admitted to the adult family home 2012.

Record review found the following progress notes (Prog notes) were written by caregivers

regarding residents' care. Progress notes spanned all three work shifts.

April 2015

The first mention of a wound on Resident #1's was noted in progress notes written by

caregivers on 4/22/15. From that date forward the wound/ wounds were frequently mentioned in

progress notes and skin check assessments completed by caregivers.



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Licensee: NORMA AND

4/22/2015 - Redness on applied ointment every toileting

4/23/2015 - still has redness on

June 2015

Resident #1 was seen by primary care physician (PCP) on 6/8/15 for (change of behavior).

During this follow-up visit there was no mention of the wound on Resident #1's At the

time of this visit Resident #1's weight was pounds. Resident #1 was not seen again until

3/8/16.

During a phone interview on 6/6/16 Resident #1's PCP verified at no time was there any mention

of the resident having an area of redness or skin issue concerns on Nor was the PCP

informed the area was treated by caregivers at the adult family home since 4/22/15 with barrier

cream with minimal effect. The PCP stated they were not informed of the condition of Resident

#1's wound until the resident was brought to the office by the provider on 3/8/16 for wound

evaluation and referral. At the time of this visit Resident #1's weight was pounds.

July 2015

Prog note 7/11/2015 - small fall, rug burn on and possible bruises on ---small

sore on

Prog note 7/12/15 - Please continue to put cream on (Resident #1) sore it is getting

bigger.

Prog note 7/13/15 - Sore is still open and has redness. It is a dime size sore been putting

ointment on it throughout the day. Will continue to monitor.

Prog note 7/22/15 cream applied.

Prog note 7/27/15 cream applied.

August 2015

Prog note 8/13/15 - has a pressure sore on Put cream on. Please continue to put

cream on and rotate at night with a pillow.

November 2015

Prog note 11/9/15 - open sore on and sore on (alert charting).

On 11/17/15 the wound was documented as open. From that date forward the wound was/did

not heal completely.

December 2015


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Prog note 12/21/15- sore on is very small.

Prog note 12/23/15 - sore appears a small hole above client no redness.

Prog note 12/24/15 - sore on

Prog note 12/29/15 - sore looks the same.

January 2016

1/4/16 - sore on is very small in size.

Prog note 1/5/16 sore is looking the same as yesterday

Prog note 1/17/2016 - Resident #1 broke out with tiny sores on Informed resident

manager who relayed the information to the provider/owner. Caregiver directed to clean the

area with soap and water with a warm washcloth ad dry it good and apply " "lotion to

Owner want(s) caregivers to mix the ointment with lotion (hand).

" is a barrier cream used to prevent development of skin irritation and wounds.

Caregivers who wish to remain anonymous were interviewed and stated the provider directed

them to thin the barrier cream mixed with hand lotion. Caregivers interviewed stated they

frequently ran out of " barrier cream for use on Resident #1's wound and would

request the barrier cream.

During interview on 5/11/16 the provider stated she had the caregivers thin the cream to make

the cream easier to apply to the affected area. When asked about the " barrier cream

the provider commented she supplied all three adult family homes with the barrier cream. When

asked why caregivers were using " thinned with hand lotion on Resident #1 the provider

stated the " barrier cream cost approximately $11.00 a tube, it was expensive and the

resident's family did not want to pay for it.

Prog notes 1/17/16 - when toileting client after breakfast notice a new bed sore where had

one but right on the of that one (alert charting)

1/17/16 - Alert charting log -----Bedsore

Daily log 1/17/16 - new bed sore on the bottom of the one that was healing.

Prog Note 1/18/16 - only thing sore on

Prog note 1/19/16 - sore is still the same in size, dot size redness around it and it is opened.

Prog note 1/19/16 - sores are still there and opened. Sore is small blister at the top of

little bit of redness around the bruise.

Prog note 1/20/16 - client still the same redness and bedsore dot size looks like getting a

small one on


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Prog note 1/20/16 - sores are red and white all sores are closed but look like they might be

trying to open.

Prog note 1/21/16 - multiple sores on about 4 of them are open now. Sores are a bit red

Prog notes 1/23/16 - sores on are getting bigger and opening up.

Prog note 1/24/16 - sores are open and red.

Prog note 1/25/16 - sores are very small and opened using donut.

Current standard of practice to decrease pressure in the presence of wounds is to not use a

"donut" cushion as the donut cushion can cause and exacerbation of the development of pressure

related skin issues.

One of the usual/common pressure relieving equipment/item to use is a Cushion (jell

filled) which was purchased by Resident #1's family for use, phone interview 5/26/16.

During interview 5/11/16 the provider stated the family brought in the donut for Resident #1's

use.

During interview on 5/25/16 and 5/26/16 family members stated they did not bring in a donut for

their use. The family stated they purchased numerous cushions for Resident #1's

use at the adult family home.

Prog note 1/25/16 - skin looks good except for has a lot of little open sores 4 or

them cg have been applying cream every two hours and sitting on donut on couch other than

sores skin looks good.

Prog note 1/26/16 - sores is the same open looks like they are getting bigger, using donut.

Prog note 1/27/16 - sores are looking better they look smaller than yesterday-surface level

opening.

Prog note 1/27/16 - has the same sores are open redness and around them some dime size

some are dot size

February 2016

Caregiver note 2/1/16 --only thing client has is sores on caregivers apply cream after

every toileting and reposition every two hours.

Prog note 2/8/16 - Client skin is intact still has sores on which are smaller than a dime

areas are drying up. client remains on alert for the sores.

2/14/16 Cell phone text message and photo regarding Resident #1 sent from a caregiver in the

home to the provider. The color photo was of the wound on Resident #1's and


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decubitus ulcer (Stage 4) that is 4cm full thickness down to the bone next to the

ulcer has gangrenous tissues." The patient (Resident #1) presented in the ER with a large wound

on near the It is large, about 8 x4 cm with necrotic debris. There is

mild surrounding erythema (redness)."

The provider's note to Resident #1's Primary Care physician (PCP) dated 16 indicated the

adult family home was ensuring the "client" Resident #1 was eating adequate amounts of

protein, pressure was alleviated by laying down and turning every 2 hours as well as

bridging hip, "a week ago the wound started turning a dark color and giving off an odor."

The same day, 16, Resident #1 was seen by PCP. was weighted pounds and was

seen in the emergency room with a wound described as 8cm by 4cm, full thickness skin, to the

bone, Stage 4 and gangrenous.

In a 5/27/16 interview the wound care nurse specialist stated describing the wound as "necrotic"

(dead tissue) which meant the same as gangrenous, the terms are interchangeable. The wound

description done by the emergency room physician and wound care nurse were essentially the

same, they used different terminology. The wound nurse went on to say at the point she

evaluated Resident #1's wound, the wound would not heal . The family made the decision to

apply comfort/palliative care measures. The physician ordered a hospital bed with a pressure

relieving mattress , and a specific dressing to be applied by a nurse and home health nurse visits

with follow-up appointment.

Prog note 3/7/16 - Client still on "alert" for sores on they are now black in color and

on the upper part of has a deep hole and a foul smell.

In Anonymous Caregiver#1's declaration, dated 3/28/16 -The caregiver stated sores were

getting worse and owner never came to look a wounds, she (the provider) directed staff to send

photos to her in TEXT form. Wound continued to get worse. The reporting caregiver was

unable to remember the exact date.

During interview Anonymous Caregiver #1 stated the provider/owner never came to the home

to assess the wound. All information including the size, shape, depth of the wound and the odor

(caregiver's were asked to describe the wound odor by the provider) was taken from photos and

text messages sent from the caregivers to the provider.

When Resident #1 returned home from hospital on 16 staff were told only the owner (who is

a licensed practical nurse) or nurse (registered Nurse) could clean wound.

Prog note 16 sore black and needs extra care by Nurse (home health or Hospice nurse).

On 3/3/16 the provider faxed Resident #1's Primary Care Physician (PCP) describing Resident

#1's "wound as healed but has come back. She described the wound as 1 1/2 inches long by 1/2

inch wide with the appearance of a hole and possible tunneling. The wound is pinkish white in

color and some sero-sanguineous draining coming from the wound. No odor. The provider

stated the wound has been coming and going for about a month now."

During interview on 5/26/16 a family member stated he was not informed/told about Resident


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Licensee: NORMA AND

#1's wound until he called the provider to inquire about not receiving a statement/billing

document. During the phone conversation the provider stated she was having computer

problems and she also wanted to let him know his /Resident #1 had a wound on

measuring 1 inch by 1 inch.

At no time prior to Resident #1's son contacting the provider, did the provider inform him his

/Resident #1 had a wound or there were areas of concern on

Throughout the 5/11/16 interview the provider continued to state she did not go to the adult

family home and physically assess or look at the wound on Resident #1's area nor did

she develop a plan of care for Resident #1's wound. The provider continued to state she relied

on the caregivers to send her pictures of Resident #1's wound on her cell phone. Based on the

cell phone photos, progress notes written by the caregivers and phone conversations with the

caregivers the provider directed Resident #1's care including care of wound.

There is no documentation in Resident #1's negotiated care plan indicating a plan was in place to

protect the resident from further injury due to the lack of wound care.

Anonymous Caregivers #1 and #3 stated they continued to inform the provider of Resident #1's

wounds and requested she come to the home to examine the wounds, however the provider did

not come to the home.

Review of Resident #1's medication log from 1/1/2016 through 3/10/16 verified the provider

documented her administration of medication ( drops) and other medication to Resident #1

on 34 separate days at various times during the day from 8AM to 8PM. At no time in those 34

days did the provider look at Resident #1's wound to assess wound care needs or check to

see if caregivers were following her directions properly.

During interview on 5/11/16 the provider stated shed reviewed all caregiver notes (progress

notes) and skin checks weekly and monthly as well as received a daily report from lead

caregivers or the resident manager.

When asked when and why she took Resident #1 to PCP for the first time on 16 to assess

the resident's wound the provider stated she took the resident when she was told by caregivers

the wound was black.

Nutrition

Resident #1's record including "I and O" (intake and oral/liquids) records and caregiver notes

documented the resident ate "100% "of food at each meal 3xs a day. Resident #1 also

received a protein supplement beverage a minimum of 2 times a day. Caregivers described the

resident as a good eater with a good appetite.

Review of Resident #1's physician's orders dated April 2015 indicated PCP requested

weights and blood pressure to be completed weekly. In December 2015 the resident's PCP

reordered the same request for weekly weight and blood pressure monitoring. No weights,

"Girth" measurements or blood pressures were reported to Resident #1's physician.


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deficiency.


WAC 388-112-0165 Who is required to complete specialty training, and when? If an

assisted living facility or adult family home serves one or more residents with special needs,

long-term care workers in those settings must complete specialty training and demonstrate

competency.

(1) If the specialty training is integrated with basic training, long-term care workers must

complete the specialty training within one hundred twenty days of hire.(2) Long-term care workers who are exempt from basic training must complete the relevant

specialty training within ninety days of hire.(3) Until competency in the specialty training has been demonstrated, long-term care workers

may not provide personal care to a resident with special needs without direct supervision in an

assisted living facility or in an adult family home.

Based on record review and interview the provider failed to ensure 7 of 9 caregivers (Caregiver

#1, #4, #6, #7, #8 and #9 ) completed specialty training prior to giving unsupervised care to

residents with identified special care needs. This failure resulted in residents receiving care

from caregivers who did not have the training to meet their special care needs.

Findings include:

Record review and interview took place on 5/11/16 unless otherwise noted.

Caregivers worked 12 hour shifts, worked alone and were unsupervised. Caregivers who wish

to remain anonymous stated during interview they believed the provider moved caregivers

around from home to home (she had three adult family homes homes) in an attempt to conceal

the fact she hired and continued to allow unqualified caregivers to work unsupervised so the

state investigators and licensors would not find out about them.

Caregiver #1's date of hire was 8/28/11. Review of Caregiver #1's employee record documented

she had not completed Speciality training either prior to or during her

employment at the home. Caregiver #1 worked alone and unsupervised in the home caring for

residents with care needs without having the required specialty training. The

provider continued to allow Caregiver #1 to work with residents with special needs from her

date of hire until she left employment in the home 5/9/16.



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Licensee: NORMA AND

Caregiver #4's date of hire was 6/15/15. Review of Caregiver #4's employee record revealed she

had no documentation she completed Specialty training. Caregiver #4 worked alone

and unsupervised from her date of hire until current caring for residents with needs

without having the required specialty training.

The provider stated in a 6/20/16 interview she thought Caregiver #4 had speciality

training.

Caregiver #6's date of hire was 11/30/15. Review of Caregiver #6's employee record

documented she had not completed or Specialty training either prior to

or during her employment at the home. Caregiver #6 worked alone and unsupervised in the

home caring for residents with and care needs without having the either

specialty.

The provider stated she was aware of the lack of speciality and other training but she intended to

fire Caregiver #6 if she was unable to correct the disqualifing crimes in her background check.

The caregiver left employment in March 2016.

Caregiver #7's date of hire was 1/12/15. Review of Resident #7's employee record documented

she did not have either or Specialty training. Caregiver #7 worked

alone and unsupervised in the home caring for residents with and

without having the specialty training.

On 6/20/16 the provider stated Caregiver #7 only worked for her a month and quit and that was

why she did not have the speciality training.

Caregiver #8's date of hire was 2/22/16. Caregiver #8 did not complete either of the specialty

trainings including and Speciality. During the time Caregiver #8 was

employed there were residents in the home with care needs requiring both and

On 6/20/16 during a phone interview the provider stated she was aware Caregiver #8 did not

have speciality training, however she thought she had specialty training.

Caregiver #9's date of hire was 12/23/15. Review of Caregiver #9's employee record

documented she had not completed Speciality training either prior to or during her

employment at the home. Caregiver #9 worked alone and unsupervised in the home caring for

residents with without having the specialty.

Despite the provider being cited on 1/15/16 for allowing a caregiver in another of her homes to

work without the required specialty training she continued to allow Caregivers #2, #4, #6, #8

and #9 to work caring for residents with or needs or both during their

employment.

On 6/20/16 when asked about the caregivers lack of specialty training the provider responded

Caregiver #8 started the training in March 2016 and could not get a certificate of the training

until she finished the training. Caregiver #8 never completed the training and there was no

verification she completed the specialty training to allow her to care for persons with those care


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Licensee: NORMA AND

needs unsupervised.






deficiency.


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