AS A ResCare Premier McCarty

Transcription

1 RICK SNYDER GOVERNOR STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS MIKE ZIMMER DIRECTOR November 3, 2015 Mayra Ramos ResCare Premier, Inc. PO Box 100 Milan, MI RE: License #: Investigation #: AS A ResCare Premier McCarty Dear Ms. Ramos: Attached is the Special Investigation Report for the above referenced facility. Due to the violations identified in the report, a written corrective action plan is required. The corrective action plan is due 15 days from the date of this letter and must include the following: How compliance with each rule will be achieved. Who is directly responsible for implementing the corrective action for each violation. Specific time frames for each violation as to when the correction will be completed or implemented. How continuing compliance will be maintained once compliance is achieved. The signature of the responsible party and a date. If you desire technical assistance in addressing these issues, please feel free to contact me. In any event, the corrective action plan is due within 15 days. Failure to submit an acceptable corrective action plan will result in disciplinary action. P.O. BOX LANSING, MICHIGAN (517)

2 Please review the enclosed documentation for accuracy and contact me with any questions. In the event that I am not available and you need to speak to someone immediately, please contact the local office at (810) Sincerely, Diane L Stier, Licensing Consultant Bureau of Community and Health Systems 1919 Parkland Drive Mt. Pleasant, MI (989) Enclosure P.O. BOX LANSING, MICHIGAN (517)

3 MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS SPECIAL INVESTIGATION REPORT I. IDENTIFYING INFORMATION License #: Investigation #: AS A Complaint Receipt Date: 09/01/2015 Investigation Initiation Date: 09/01/2015 Report Due Date: 10/31/2015 Licensee Name: Licensee Address: ResCare Premier, Inc Linn Station Road Louisville, KY Licensee Telephone #: (734) Administrator: Licensee Designee: Name of Facility: Facility Address: Mayra Ramos, Designee Mayra Ramos, Designee ResCare Premier McCarty 3475 Hospital Road Saginaw, MI Facility Telephone #: (989) Original Issuance Date: 03/30/2011 License Status: REGULAR Effective Date: 10/26/2013 Expiration Date: 10/25/2015 Capacity: 6 Program Type: MENTALLY ILL DEVELOPMENTALLY DISABLED PHYSICALLY HANDICAPPED TRAUMATICALLY BRAIN INJURED 1

4 II. ALLEGATION(S) Two female staff took a male resident to a private home to get his hair cut and left the resident there alone for over an hour. One staff was left at the facility with five residents. Additional Findings Violation Established? Yes Yes Yes III. METHODOLOGY 09/01/2015 Special Investigation Intake 2015A /01/2015 Special Investigation Initiated - Letter to ORR 09/01/2015 Contact - Document Received IR from Home Manager 09/04/2015 Inspection Completed On-site Interviews, documents 09/04/2015 Contact - Face to Face Resident 09/08/2015 Referral - Protective Services 09/08/2015 Contact - Telephone call received From RRA Schaefer 09/10/2015 Contact - Face to Face Second interviews 09/10/2015 Contact - Document Received Pictures, documentation 11/03/2015 Exit Conference Licensee Designee ALLEGATION: Two female staff took a male resident to a private home to get his hair cut and left the resident there alone for over an hour. INVESTIGATION: On 9/1/15, Melynda Schaefer, Recipient Rights Advisor (RRA) from Saginaw County Community Mental Health Authority (SCCMHA), notified me that she had received an 2

5 allegation regarding this facility. Specifically, RRA Schaefer reported that Resident A had told her that two staff from the AFC home took him to get his hair cut on 8/29/15. According to RRA Schaefer, Resident A reported that the staff left him at a house for nearly an hour where the barber cut his hair. RRA Schaefer reported that Resident A told her something wasn t right and he was worried the whole time, because the staff just left him there and he did not know if they were coming back. On 9/1/15, I received and reviewed an Incident/Accident Report completed by staff Latasha Owens on 8/31/15. According to the report, on 8/3015, Ms. Owens told Resident that his haircut looked nice, and he immediately stated to me and [staff] Dawn Botello that Ebony [Hatfield] and Gloria [Thomas] took him on 27 th Street and they left him there alone for an hour with the barber and he thought it was a trap house and that his rights was violated. (sic) Ms. Owens noted that she told Resident A to tell Home Manager Angie Angela Leach, and that she (Ms. Owens) called RRA Melynda Schaefer to report this on 8/31/15. On 9/4/15, RRA Schaefer reported that she spoke with Resident A s case manager, Halley Goodrow, who said that Resident A has a history of multiple substance abuse, has done well since coming to the AFC home about three years ago, and would likely have been very nervous about being left somewhere alone. On 9/4/15, Resident A reported that last Saturday afternoon [8/29/15] staff Ms. Ebony and Ms. Gloria had taken him to get a haircut. Resident A said that Ms. Ebony said to him, Mr. (A), it s time for you to get a haircut. I m going to take you to get a haircut. Resident A said that he had gotten a haircut from the same man before at a business on Dixie Highway but that this time they took him to a vacant house with just a chair and left me there about 35 or 45 minutes. Resident A said the staff told him they were going to the store. Resident A said, What if my sugar went low? I could have been in deathly peril. Resident A said that staff Ebony Hatfield spoke with the barber for a few minutes when they arrived at the house, and that it appeared Ms. Ebony knew him. Resident A said he thought it was odd that staff just left him at the house, because when we go to a movie even, they might let me go to the restroom by myself but they come check if I take too long. This was unusual! Resident A said that he was nervous, real nervous while he was at the house. Resident A said no one was there except him and the barber, and he was afraid that it was a trap house, which he described as someplace that you think it s on the up and up, then somebody does something to you. Resident A said he had never seen the street or the houses before and would not have known how to get away from there. Resident A said staff did finally come to get him, and when they left he saw two signs on the street, one which read, Dead End and another which read 27 th Street. On 9/4/15, Program Director Holly Yates said that she and Home Manager Angie Leach got to the AFC home on Monday, 8/31/15, at the same time, around 8 AM. Ms. Yates said that Resident A came immediately to tell them that Ebony (Hatfield) and Gloria (Thomas) took him to a house on 27 th Street and left him on Saturday. Ms. Yates said that both Ms. Hatfield and Ms. Thomas have worked at the facility for some time. Ms. 3

6 Yates said that staff should have gotten permission before taking Resident A away from the facility, and that she had checked with the on-call supervisor for the weekend, Crystal, and found that no one had called requesting such permission. On 9/4/15, staff Gloria Thomas said that she has worked at the facility for around eight years. Ms. Thomas said she knew that we were conducting an investigation into something about (Resident A) being left alone at a barbershop. Ms. Thomas said she heard about it from one of her friends, who heard about it while she was eating out or something. Ms. Thomas said that she worked on 8/29/15 from 7 AM 3 PM. Ms. Thomas said she drove herself to work that day but her grandson needed the car. Ms. Thomas said, I was going to leave work early, like 2 PM, so I could take him the car. Ms. Thomas said that Ms. Hatfield came into work, though, so there was (sic) three of us working, so I decided to take the car home. Ms. Thomas said she dropped the car at her home [2507 Tausand] close to noon, she thought. Ms. Thomas said that Ms. Hatfield was going to pick her up. Ms. Thomas said that Ms. Hatfield told her that Resident A could get a free haircut that day, so they took him to a barbershop on Dixie Highway, a beige or brown building. Ms. Thomas insisted that they took Resident A to a legitimate barbershop. Ms. Thomas said the barber s name was Bubba and that Ms. Hatfield knew him. Ms. Thomas said there was no receipt for the haircut because it was free. Ms. Thomas said that she and Ms. Hatfield were in the shop with Resident A at first, and then the two staff went outside to smoke, but we could still see him while he was getting his haircut. There was a big window. Ms. Thomas said the two staff went back into the shop when they finished smoking, and listened to the gospel music that was playing. Ms. Thomas said that they played gospel music in the car once they saw how much Resident A enjoyed it. Ms. Thomas said that when the haircut was finished they returned to the AFC home. Ms. Thomas said that Resident A was never out of her sight once Ms. Hatfield and Resident A picked her up in the van at her house. Ms. Thomas said that she gets along fine with Resident A, that there is no one Resident A seems to like or dislike particularly. When asked if she has ever known Resident A to lie, Ms. Thomas said, No, not that I know of. When asked why her story did not match what Resident A reported, Ms. Thomas said, (Resident A) is lying. On 9/4/15, staff Ebony Hatfield said she did not know what our investigation was about. Ms. Hatfield said that she had left work early on Friday so she came in to work around 11 AM on Saturday, 8/29/15, to make up her hours. Ms. Hatfield said that she knew a barber who gave free haircuts to people like (Resident A) for a few hours on some Saturdays, so she knocked on Resident A s door to see if he wanted to get a haircut. Ms. Hatfield said Resident A said he would be ready in about 10 or 15 minutes, so she put lunch (lasagna) in the oven and then left with Resident A. Ms. Hatfield said that staff Gloria Thomas was gone when she and Resident A left, and that Ms. Thomas had asked her earlier if she could pick her up. Ms. Hatfield said that when she pulled up at Ms. Thomas house, Ms. Thomas was standing in the driveway. Ms. Hatfield said she had given Ms. Thomas rides to and from work before so she knew where she lived. Ms. Hatfield said that Resident A was in the back seat in the van, and Ms. Thomas got into the front passenger seat. Ms. Hatfield said they then went on Dixie to get Resident A s haircut. Ms. Hatfield said they took Resident A to a barbershop in a blue building 4

7 across the street from Butterfield s car lot. Ms. Hatfield said, You have to park in the back. Ms. Hatfield said there are two barbershops, one called something like Unique Cuts. Ms. Hatfield said, The other one is the one we went to. Ms. Hatfield said the barber s name is Michael but people call him Bubble and he does free haircuts sometimes. Ms. Hatfield denied that she and Ms. Thomas left Resident A there but said that the two staff went outside to smoke for about 10 minutes. When asked what the inside of the barbershop looked like, Ms. Hatfield said there was a barber chair and other chairs lined up against the wall, but it looks like it could use a cleanup. When asked if she had gotten permission to take Resident A out of the AFC home and to use the facility van, Ms. Hatfield said she had not. Ms. Hatfield said, It was Ms. Angie s birthday, and Crystal was on call and I didn t want to bother her. Ms. Hatfield provided a phone number for Michael/ Bubble. When asked why Resident A would say that she and Ms. Thomas had taken him to a house on 27 th Street instead of to a barber shop, Ms. Hatfield said she did not know but that he was not telling the truth. On 9/4/15, staff Stephanie Vasquez reported that she has worked at the facility for about two years. Ms. Vasquez said she thought the investigation was about a situation last Saturday involving Resident A. Ms. Vasquez said she had heard staff Andrea and Latasha talking about it, because Resident A had told them about it. Ms. Vasquez said that on Sunday, 8/30/15, Resident A came into the office to get his nebulizer treatment and she told him that his hair looked nice. Ms. Vasquez reported that Resident A then told her he thought he had been taken to a trap house on Saturday. Ms. Vasquez said she worked 1 st shift on Saturday and that Ms. Thomas and Ms. Hatfield told her they were leaving before they left. Ms. Vasquez said that Ms. Thomas had to drop her car off at home, and Ms. Vasquez thought that Ms. Thomas had called Ms. Hatfield to come in to work so she could use the work van to pick Ms. Thomas up at her home. Ms. Vasquez said that management knew about Ms. Hatfield coming in to make up hours from the previous day, but not about using the van. When asked what kind of supervision Resident A needs, Ms. Vasquez said that staff have to monitor Resident A in the community, and that they check on him in the home every 20 minutes. Ms. Vasquez said she was not aware that Ms. Hatfield had taken Resident A with her, and that perhaps taking Resident A to get his hair cut was a reason for Ms. Hatfield to take the van to pick up Ms. Thomas. On 9/4/15, I received and reviewed a copy of Resident A s Assessment Plan for AFC Residents, dated 5/1/15. According to the plan, Resident A does/may not move independently in the community and requires 24-hour supervision. Resident A s Person Centered Plan notes that the resident is to be supervised in the community. On 9/4/15, RRA Schaefer, Program Directory Holly Yates, Resident A and I drove to the barbershops on Dixie Highway across from Butterfield Auto. We observed one beige/brown building identified as a barbershop. We also observed adjacent to this building a bright blue building that had potential business space on two floors but which was vacant, padlocked, and had realtor signage noting the property was available. Resident A identified the labeled barbershop as the place Ms. Hatfield had taken him for a haircut on a prior occasion, but said that neither of these buildings was where he had 5

8 been taken on 8/29/15. We drove to several locations with dead ends on 27 th Street, but Resident A did not identify any house as the house to which he had been taken. On 9/8/15, I received a phone message from RRA Melynda Schaefer, reporting that Program Director Holly Yates had called her to say they had found the house that staff had taken Resident A to on 8/29/15. RRA Schaefer reported that another staff had told Ms. Yates that either Ms. Hatfield or Ms. Thomas had mentioned taking Resident A to someplace on Brunko, so Ms. Yates had driven Resident A to that street, off Dixie Highway, and Resident A had identified the house at 2671 Brunko Court as the house at which he had been left by Ms. Hatfield and Ms. Thomas. RRA Schaefer also reported that she had contacted the realtor (Geraldine Doxie) for the blue building to which Ms. Hatfield alleged they had taken Resident A, and had been told that the building had been foreclosed in 2014 and had been vacant since that time. On 9/8/15, I received an with photo attachments from RRA Schaefer. RRA Schaefer included photos of the house at 2671 Brunko Court. Also included were photos of the Dead End sign and the 27 th Street/Brunko Court street sign. Additionally, RRA Schaefer had included photos of Michael Hamilton, tagged as bubblestar_the_barber from a social media website. On 9/10/15, Resident A said he was glad they were able to find the house where staff had taken him for the haircut. Resident A said, They [staff] were calling me a liar. They were trying to set me up! On 9/10/15, RRA Melynda Schaefer reported that she had identified Michael/ Bubble as Michael Hamilton. RRA Schaefer reported that she had interviewed Mr. Hamilton, who told her that the upstairs portion of 4777 Dixie Highway (the blue building adjacent to the barbershop) was his shop and told her he would fax her a copy of his barber s license and his lease, which he said he had just terminated that day. On 9/10/15, staff Dawn Botello reported Resident A had told her on Sunday, 8/30/15, that Ms. Hatfield and Ms. Thomas left him at some house when he was getting his hair cut. According to Ms. Botello, Resident A said there was nothing in the house except the chair he sat in to get his hair cut. Ms. Botello said, He called it a trap house. Ms. Botello said that later that same day, when she was alone with Ms. Hatfield in the office, Ms. Hatfield told her that they had taken Resident A to Bubble s house, not the actual barbershop. Ms. Botello said she asked where that was, and Ms. Hatfield told her it was on Brunko. Ms. Botello said, I was trying to play like I didn t know what was going on. When asked if Ms. Hatfield admitted leaving Resident A alone at that house, Ms. Botello said she did not, but that Resident A had told her he was left alone at the house. Ms. Botello said she has not known Resident A to lie, and that she believes Resident A. On 9/10/15, staff Gloria Thomas was re-interviewed. At this interview, Ms. Thomas said she remembered Ms. Hatfield and Resident A picking her up and driving to a house to get Resident A s haircut. Ms. Thomas insisted, however, that she did not leave Resident A. Ms. Thomas said, Ebony [Hatfield] went in and talked to Bubble. Then she went to the store to get water and came back in about five minutes, and I was 6

9 sitting on the porch. Ms. Thomas said that Resident A could have seen the van through the window because the window blinds were open. Ms. Thomas had no explanation as to why she lied during her previous interview. On 9/10/15, staff Ebony Hatfield was asked if there was anything she wanted to change from her statements she made in her previous interview, and Ms. Hatfield said she did not. When confronted with the pictures of the house on Brunko Court and other information, Ms. Hatfield said, When I took him [Resident A] the first time, it was to the barbershop. I thought, being his own guardian, it would be okay. I didn t mean him no harm. Ms. Hatfield said she was trying to do a good thing for Resident A by getting him a free haircut. Ms. Hatfield denied that she left to go to the store to get water during the time that Resident A was getting his hair cut. Ms. Hatfield said she always had bottles of water in the van, so there was no need to go to the store. Ms. Hatfield had no explanation as to why her account of the time and that of Ms. Thomas did not match. APPLICABLE RULE R Resident care; licensee responsibilities. (2) A licensee shall provide supervision, protection, and personal care as defined in the act and as specified in the resident's written assessment plan. ANALYSIS: CONCLUSION: Staff failed to provide the required supervision and protection to Resident A when they left him unattended and unsupervised in a house and with an individual with whom he was not familiar. VIOLATION ESTABLISHED ALLEGATION: One staff was left at the facility with five residents. INVESTIGATION: On 9/1/15, Melynda Schaefer, Recipient Rights Advisor (RRA) from Saginaw County Community Mental Health Authority (SCCMHA), notified me that she had received an allegation regarding this facility. Specifically, when two staff left the facility with Resident A, one staff was left in the home with five residents during the lunch period. On 9/4/15, Program Director Holly Yates reported that generally there are two staff scheduled on 1 st and 2 nd shifts, with one staff scheduled for 3 rd shift when residents are sleeping. Ms. Yates said that a third staff is scheduled if residents have appointments or outings. On 9/4/15, staff Stephanie Vasquez reported that when Ms. Hatfield left to pick up Ms. Thomas, Ms. Vasquez knew that both Ms. Hatfield and Ms. Thomas were gone, since 7

10 Ms. Thomas had left the facility earlier to take her car home. Ms. Vasquez said she was not initially aware that Ms. Hatfield had taken Resident A with her. Ms. Vasquez said that it was not feasible for her to be left alone with the five residents, especially during lunch time. Ms. Vasquez said that the lasagna for lunch went into the oven around 10:30 AM, and Ms. Thomas and Ms. Hatfield did not return with Resident A until around 1 PM, so she was the only staff in the home for at least two hours. Ms. Vasquez said she was responsible for passing medications, and was also doing Resident B s tube feeding. Ms. Vasquez said there is also a second resident who requires tube feeding. Ms. Vasquez said that there are supposed to be two staff on duty except during sleeping hours. APPLICABLE RULE R Staffing requirements. (2) A licensee shall have sufficient direct care staff on duty at all times for the supervision, personal care, and protection of residents and to provide the services specified in the resident's resident care agreement and assessment plan. ANALYSIS: CONCLUSION: Although sufficient staff were scheduled, staff Gloria Thomas and Ebony Hatfield left the facility with one resident, leaving only one staff person in the facility to administer medications, tube feedings, and provide supervision to five residents during lunch time. The fact that two staff are regularly scheduled for this shift is an indication of the licensee s awareness of the need for at least two staff to provide care for the residents during the shift. On 8/29/15, when only one staff was present from at or around 11:00 a.m. until at or around 1:00 p.m., there was not a sufficient number of staff present to provide services to the residents present in the home at the time. VIOLATION ESTABLISHED ADDITIONAL FINDINGS: INVESTIGATION: Staff Gloria Thomas and Ebony Hatfield were interviewed twice during the course of this investigation. It is apparent from their statements during the interviews and from the other evidence gathered in the course of the investigation concerning the location where Resident A was taken for a haircut on 8/29/15 that Ms. Thomas and Ms. Hatfield were not truthful in their initial interviews. Both staff also said that Resident A was lying in his report of the incident. 8

11 APPLICABLE RULE R Qualifications of administrator, direct care staff, licensee, and members of the household; provision of names of employee, volunteer, or member of the household on parole or probation or convicted of felony; food service staff. (11) A licensee, direct care staff, and an administrator shall be willing to cooperate fully with a resident, the resident's family, a designated representative of the resident and the responsible agency. ANALYSIS: CONCLUSION: Staff did not cooperate with Resident A when they stated that the resident was lying about the events he reported. Staff did not cooperate with the responsible agency (Saginaw County CMHA) when they lied to the Recipient Rights Advisor for the agency during the course of the investigation. VIOLATION ESTABLISHED APPLICABLE RULE R Resident protection. (3) A resident shall be treated with dignity and his or her personal needs, including protection and safety, shall be attended to at all times in accordance with the provisions of the act. ANALYSIS: CONCLUSION: Resident A was not treated with dignity, and his need for protection and safety was not attended when staff left him in a situation in which he did not feel safe. Resident A s perception that staff had left him and were not available is the relevant point, whether or not it can ever be determined if they were, in fact, outside the house. VIOLATION ESTABLISHED 9

12 During an exit conference on 11/3/15, licensee designee Mayra Ramos that all staff were in-serviced immediately on procedures related to contacting appropriate supervision when situations like this arise. Ms. Ramos noted that the staff person who was left with the five residents could have and should have called the manager immediately but did not. Ms. Ramos said that had management been contacted, additional staff would have been provided immediately to provide adequately for the care of the residents. Ms. Ramos stated that they also reviewed with staff the importance of maintaining an adequate staff-to-resident ratio at all times. Ms. Ramos reported that staff Ebony Hatfield and Gloria Thomas were terminated on 9/18/15. Ms. Ramos said she would submit a written corrective action plan as soon as she receives this written report. IV. RECOMMENDATION Pending receipt of an acceptable corrective action plan, I recommend continuation of the current status of the license of this AFC adult small group home (capacity 1-6). Diane L Stier Licensing Consultant November 3, 2015 Date Approved By: Mary E Holton Area Manager November 3, 2015 Date 10