STATE OF MICHIGAN GRETCHEN WHITMER
GOVERNOR DEPARTMENT OF LICENSING AND REGULATORY AFFAIRSLANSING
ORLENE HAWKS DIRECTOR
June 29, 2020 Angela Joquico
Special Tree Residential Centers, LTD Ste. 2 10909 Hannan Romulus, MI 48174 RE: License #: Investigation #: AS820242601 2020A0116023 RiverView Dear Ms. Joquico:
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.
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 (313) 456-0380.
Sincerely,
Pandrea Robinson, Licensing Consultant Bureau of Community and Health Systems Cadillac Pl. Ste 9-100
3026 W. Grand Blvd Detroit, MI 48202 (313) 319-9682 enclosure
MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS
SPECIAL INVESTIGATION REPORT
THIS REPORT CONTAINS QUOTED PROFANITY
I. IDENTIFYING INFORMATION
License #: AS820242601
Investigation #: 2020A0116023
Complaint Receipt Date: 06/02/2020
Investigation Initiation Date: 06/02/2020
Report Due Date: 08/01/2020
Licensee Name: Special Tree Residential Centers, LTD
Licensee Address: 39000 Chase Road Romulus, MI 48174
Licensee Telephone #: (734) 239-1937
Licensee Designee: Angela Joquico
Name of Facility: RiverView
Facility Address: 17436 Poplar St.
Riverview, MI 48192-7640
Facility Telephone #: (734) 239-1937
Original Issuance Date: 10/29/2002
License Status: REGULAR
Effective Date: 05/08/2019
Expiration Date: 05/07/2021
Capacity: 6
Program Type: TRAUMATICALLY BRAIN INJURED
II. ALLEGATION(S)
III. METHODOLOGY
06/02/2020 Special Investigation Intake 2020A0116023
06/02/2020 Special Investigation Initiated - Telephone Interviewed licensee designee Angie Joquico. 06/10/2020 Contact - Telephone call made
Violation Established?
Incident report received states that on 05/28/20 Resident A was verbally abusive to staff Kevina Lewis and so she became verbally abusive to Resident A as well. Then Ms. Lewis pushed Resident A's wheelchair causing him to flip over and hit the floor. Two other staff in the home observed the incident and contacted APS. Resident A was sent to the hospital to be examined.
Interviewed staff Nicole Koniarz and Arinn Moore and Resident A. 06/10/2020 Contact - Telephone call made
Interviewed former staff Kevina Lewis. 06/10/2020 Contact - Telephone call made
Interviewed assigned Adult Protective Services Worker (APS) Marlena Murphy.
06/10/2020 Inspection Completed-BCAL Sub. Compliance No onsite conducted due to Covid-19 Pandemic
06/24/2020 Exit Conference
With licensee designee Angie Joquico.
ALLEGATION:
Incident report received states that on 05/28/20 Resident A was verbally
abusive to staff Kevina Lewis and so she became verbally abusive to Resident A as well. Then Ms. Lewis pushed Resident A's wheelchair causing him to flip over and hit the floor. Two other staff in the home observed the incident and contacted APS. Resident A was sent to the hospital to be examined.
INVESTIGATION:
I interviewed licensee designee Ms. Joquico on 06/02/20 and she reported that Ms. Lewis is currently suspended pending investigation. Ms. Joquico reported that APS was called and that they have interviewed Resident A and staff on 05/29/20. Ms. Joquico reported that Resident A was examined and did not sustain any injuries. I interviewed staff Nicole Koniarz on 06/10/20 and she reported being present when the incident occurred. Ms. Koniarz reported that Ms. Lewis was in the kitchen
making her some lunch and she heard her tell Resident A “get out of the kitchen because I do not want to fuck with you today.” Ms. Koniarz reported that Resident A started cussing and going off on Ms. Lewis and while doing so she went over to him and pushed him hard causing him to fall out of his wheelchair to the ground. Ms. Koniarz reported that she could tell by the look on Resident A’s face that he was scared. She reported that she along with staff Ashea Young picked Resident A up and looked him over to see if he was hurt. Ms. Koniarz reported no injuries were
observed, but as a precaution they notified the on-call nurse and informed Ms. Joquico of what occurred. Ms. Koniaez reported the nurse recommended that Resident A be sent to the hospital and evaluated. She reported Resident A did not sustain any injuries.
I interviewed staff Arinn Moore. Ms. Moore reported that she was in the home when the incident occurred and reported she did not actually observe Ms. Lewis push Resident A out of his wheelchair, but overhead her telling Resident A “stop touching my fucking food.” Ms. Moore reported that she heard a loud noise which she learned was Resident A falling to the floor. Ms. Moore reported she was busy passing
medications at the time. Ms. Moore reported that Resident A has behaviors and reported that day it appears he was agitating Ms. Lewis, however, she reported that does not justify what Ms. Lewis did. Ms. Moore reported that Ms. Lewis is normally a very easy going and nice person. She reported she was always kind to the residents and really cared about them. Ms. Moore reported she was shocked at the way Ms. Lewis reacted.
I attempted to interview Resident A on 06/10/20. Resident A was difficult to
understand and appeared to mumble when responding to questions. Resident A was unable to relay any information specific to the incident. The interview was concluded. I interviewed former staff Kevina Lewis and she reported that she did not push
Resident A out of his wheelchair as reported or with any ill-intent. Ms. Lewis reported while she was preparing food Resident A kept coming into the kitchen touching things and she was constantly re-directing him and asking him to leave out of the kitchen area for his own safety. Ms. Lewis denied that she cursed or used vulgarity while speaking to Resident A. Ms. Lewis reported that Resident A continued to come in the kitchen and was being rude and disrespectful to her, so she went behind his wheelchair to move him out of the kitchen, but unbeknownst to her, he had his feet planted on the floor, causing the wheelchair to flip and him to fall to the floor. Ms. Lewis reported she attempted to help Resident A up off the floor, but he was
agitated, combative and would not let her touch him. Ms. Lewis reported she asked the other staff in the home to help pick Resident A up off the floor, which they did. Ms. Lewis reported that Resident A puts his feet on the ground all the time when he does not want staff to wheel him out of a certain area and when he is having a behavior. Ms. Lewis admitted that she should have checked and ensured his feet were on the footrests before attempting to move him. Ms. Lewis reported she would never intentionally hurt anyone and reported that she genuinely loves and cares about all of the residents. Ms. Lewis appeared remorseful and was crying during the interview. Ms. Lewis reported that she was relieved that Resident A was not hurt. Ms. Lewis reported that she was terminated from her job and has not returned to the facility.
I interviewed APS Ms. Murphy on 06/10/20 and she reported that she is investigating the allegations and will likely be substantiating the allegation of physical abuse. Ms.
Murphy reported that she spoke with Resident A’s guardian and he reported being notified of the incident and was satisfied with the steps taken by the home. Ms. Murphy reported that he shared with her that the home provides great care and believes that this was an isolated incident.
I conducted the exit conference with Ms. Joquico on 06/24/20 and informed her of the findings of the investigation. Ms. Joquico reported an understanding.
APPLICABLE RULE
R 400.14308 Resident behavior interventions prohibitions.
(1) A licensee shall not mistreat a resident and shall not permit the administrator, direct care staff, employees, volunteers who are under the direction of the licensee, visitors, or other occupants of the home to mistreat a resident. Mistreatment includes any intentional action or omission which exposes a resident to a serious risk or physical or emotional harm or the deliberate infliction of pain by any means.
ANALYSIS:
Based on the findings of the investigation which included
interviews with Ms. Joquico, Ms. Koniarz, Ms. Moore, Ms. Lewis and Ms. Murphy, I am able to corroborate the allegation.
Ms. Koniarz reported that Ms. Lewis was upset at Resident A and intentionally pushed him causing him to fall on the floor. Ms. Moore reported that although she did not witness Ms. Lewis push Resident A out of his wheelchair to the ground, she heard Ms. Lewis cursing and upset with Resident A, prior to hearing the loud noise that she later learned was Resident A hitting the ground.
Ms. Murphy reported that based on the information she has obtained during her investigation; she will be substantiating for physical abuse.
Ms. Lewis denied any intent to harm Resident A, but admitted that after several attempts to re-direct him out of the kitchen failed, she immediately went to push him out of the area, which in turn caused him to fall out of his chair onto the ground. Ms. Lewis admitted that she did not check to ensure that his feet were resting on his footrest before wheeling him out of the kitchen area, causing him to fall.
This violation is established as Ms. Lewis appeared to be
agitated with Resident A’s behaviors and his refusal to leave out of the kitchen area after repeated re-direction and his failure to comply. Ms. Lewis hastily pushed Resident A causing him to fall out of his wheelchair onto the floor. Resident A was sent to the hospital to be evaluated but did not sustain any injuries.
IV. RECOMMENDATION
Contingent upon receipt of an acceptable corrective action plan, I recommend the status of the license remain unchanged.
__ 06/25/20 Pandrea Robinson Licensing Consultant Date Approved By: _____________________________________06/29/2020 Ardra Hunter Area Manager Date
