STATE OF MICHIGAN GRETCHEN WHITMER
GOVERNOR DEPARTMENT OF LICENSING AND REGULATORY AFFAIRSLANSING
ORLENE HAWKS DIRECTOR March 1st, 2021
Mary Martin
American House Wyoming 5812 Village Dr SW
Wyoming, MI 48519 RE: License #:
Investigation #: AH4104028962021A1021019
American House Wyoming Dear Ms. Martin:
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 authorized representative 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 (517) 284-9730.
Sincerely,
Kimberly Horst, Licensing Staff
Bureau of Community and Health Systems 611 W. Ottawa Street
Lansing, MI 48909 enclosure
MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS
SPECIAL INVESTIGATION REPORT I. IDENTIFYING INFORMATION
License #: AH410402896
Investigation #: 2021A1021019
Complaint Receipt Date: 02/16/2021
Investigation Initiation Date: 02/16/2021
Report Due Date: 04/18/2021
Licensee Name: AH Wyoming Subtenant LLC
Licensee Address: STE 1600
One Towne Square Southfield, MI 48076
Licensee Telephone #: (248) 827-1700
Administrator/ Authorized
Representative: Mary Martin
Name of Facility: American House Wyoming
Facility Address: 5812 Village Dr SW
Wyoming, MI 48519
Facility Telephone #: (616) 622-2420
Original Issuance Date: 11/05/2020
License Status: TEMPORARY
Effective Date: 11/05/2020
Expiration Date: 05/04/2021
Capacity: 166
Program Type: AGED
II. ALLEGATION(S)
III. METHODOLOGY
02/16/2021 Special Investigation Intake 2021A1021019
02/16/2021 Special Investigation Initiated - Letter referral sent to Adult Protective Services 02/17/2021 Inspection Completed On-site
02/23/2021 Contact-Documents Received
Received MAR and call light response time 03/01/2021 Exit Conference
Exit Conference with authorized representative Mary Martin The complainant identified some concerns that were not related to home for the aged licensing rules and statutes. Therefore, only specific items pertaining to homes for the aged provisions of care were considered for investigation. The following items were those that could be considered under the scope of licensing.
ALLEGATION
:
Facility is restricting family visitation. INVESTIGATION:
On 2/16/21, the licensing unit received a complaint with allegations the facility is not arranging video telephone calls and is restricting Resident A’s family member visitation. The complainant alleged Resident A is on hospice.
Violation Established?
Facility is restricting family visitation. Yes
Facility has lost personal items. No
Resident A has pressure ulcer due to neglect. No
Facility has insufficient staff. Yes
On 2/16/21, the allegations in this report were sent to centralized intake at Adult Protective Services (APS).
On 2/17/21, I interviewed administrator Mary Martin at the facility. Ms. Martin reported the life enrichment department is responsible for organizing Zoom video calls with the residents and their family members. Ms. Martin reported the facility has organized these calls since March 2020 due to the Covid19 pandemic. Ms. Martin denied the allegation that the facility is not organizing these calls. Ms. Martin
reported after Thanksgiving the facility stopped visitation with hospice residents due to a Covid19 outbreak at the facility. Ms. Martin reported the Ombudsman contacted the facility regarding the visitations and hospice visitations were resumed on
February 11th. Ms. Martin reported she believed the facility could only allow family visitation if the resident were at end of life. Ms. Martin reported the facility is now allowing family members to visit if their loved one if on hospice.
On 2/17/21, I interviewed life enrichment coordinator Ashley Kelly at the facility. Ms. Kelly reported her department has been organizing video calls since the Covid19 pandemic began in March 2020. Ms. Kelly reported at the beginning of the
pandemic, emails were sent out to family members informing them of the process to schedule a video call. Ms. Kelly reported the facility has 2 iPads for the residents to use for the video call. Ms. Kelly reported her department is very flexible in
scheduling these video calls and are trying to keep the residents connected with their families. Ms. Kelly reported the video calls can happen at any time and care staff can assist with them if life enrichment is not available. Ms. Kelly reported each life enrichment coordinator does 1:1 visits with the residents because the facility is unable to do group events. Ms. Kelly reported she has visited with Resident A and Resident A has not expressed interest to do a video call with her family. Ms. Kelly reported last week the facility opened their policy to allow for hospice residents to have family visitation. Ms. Kelly reported she contacted Relative A1 regarding the policy change.
I reviewed Michigan Department of Health and Human Services Order titled “Requirements for Residential Care Facilities” that is dated October 6th, 2020. The definition in the order read,
Facilities may permit indoor visitation only in the following circumstances: (b) When a resident is in “serious or critical condition or in hospice care”.
APPLICABLE RULE
R 325.1917 Compliance with other laws, codes, and ordinances.
(1) A home shall comply with all applicable laws and shall furnish such evidence as the director shall require to show compliance with all local laws, codes, and ordinances.
ANALYSIS: Due to the Covid-19 pandemic, visitation has been limited at the facility. Michigan Department of Health and Human Service (MDHSS) enacted an order on visitation allowing visitation for residents that are on hospice care. The facility was not following this order from end of November until February 11th, 2021.
CONCLUSION: VIOLATION ESTABLISHED
ALLEGATION
:
Facility has lost personal items. INVESTIGATION:
The complainant alleged the facility has lost belongings of resident, such as Poise pads, sent by family members.
Ms. Martin reported she has not been notified by family members that personal items have been misplaced.
On 2/16/21, I interviewed assistant wellness director Jaqueline Henderson at the facility. Ms. Henderson reported family members drop off items at the front door and then the front desk brings items to the resident room. Ms. Henderson reported she contacts family members when residents do not have items, such as incontinence products. Ms. Henderson reported she has never contacted Resident A’s family on lack of incontinence products.
On 2/16/21, I interviewed medication technician Tamatha Lewis at the facility. Ms. Lewis reported she would contact family members if a resident does not have required incontinence products. Ms. Lewis reported she has never contacted Resident A’s family to request incontinence products.
On 2/16/21, I observed Resident A’s room. In Resident A’s room there was a significant supply of incontinent products.
APPLICABLE RULE
R 325.1921 Governing bodies, administrators, and supervisors. (1) The owner, operator, and governing body of a home shall do all of the following:
(b) Assure that the home maintains an organized program to provide room and board, protection,
supervision, assistance, and supervised personal care for its residents.
For Reference:
R 325.1901 Definitions.
(16) "Protection" means the continual responsibility of the home to take reasonable action to ensure the health, safety, and well-being of a resident as indicated in the resident's service plan, including protection from physical harm, humiliation, intimidation, and social, moral, financial, and personal exploitation while on the premises, while under the supervision of the home or an agent or employee of the home, or when the resident's service plan states that the resident needs continuous supervision.
ANALYSIS: Interviews with staff members revealed the facility has never contacted Resident A’s family members to request additional supply of incontinence products due to the facility losing the products. Observations made at the facility revealed Resident A has a significant supply of incontinence products.
CONCLUSION: VIOLATION NOT ESTABLISHED
ALLEGATION
:
Resident A has pressure ulcer due to neglect. INVESTIGATION:
The complainant alleged Resident A has developed a severe pressure ulcer because of being left in bed.
Ms. Henderson reported Resident A prefers to sit in her chair which causes the skin breakdown. Ms. Henderson reported Resident A is on a toileting schedule every two-three hours. Ms. Henderson reported Resident A has a prescription for Destin that medication technicians apply daily.
On 2/17/21, I interviewed caregiver Deborah Taylor at the facility. Ms. Taylor reported caregivers get Resident A up every two hours to prevent additional skin breakdown. Ms. Taylor reported caregivers are to apply ointment on Resident A’s bottom. Ms. Taylor reported Resident A is not left in bed and that it is Resident A’s choice to be left in her chair or bed.
Ms. Lewis reported caregivers will get Resident A up every two hours to prevent skin breakdown. Ms. Lewis reported Resident A has a pressure relief cushion but refuses to sit on the cushion. Ms. Lewis reported Resident A refuses to get up and walk around. Ms. Lewis reported caregivers put ointment on Resident A’s bottom. Ms. Lewis reported Resident A is active with hospice for additional care.
On 2/17/21, I interviewed Faith Hospice case manager Jennifer Sherrod at the facility. Ms. Sherrod reported Resident A does not have a pressure ulcer just skin breakdown. Ms. Sherrod reported Resident A sits in her recliner chair and this is causing the skin breakdown. Ms. Sherrod reported Resident A was with a home care agency but was discharged due to not meeting goals and refusing to participate in care. Ms. Sherrod reported Resident A has a Rojo pressure relief cushion that she refuses to use. Ms. Sherrod reported the facility is to get Resident A up every two hours. Ms. Sherrod reported she feels the facility is not neglecting Resident A. On 2/17/21, I interviewed Resident A at the facility. Resident A was observed to be sitting in her recliner chair in her room. Resident A reported she receives good care at the facility. Resident A reported no concerns with being neglected at the facility. I reviewed Resident A’s service plan. The service plan read,
“staff to toilet every 2-3 hours.”
APPLICABLE RULE
R 325.1931 Employees; general provisions.
(2) A home shall treat a resident with dignity and his or her personal needs, including protection and safety, shall be attended to consistent with the resident's service plan. ANALYSIS: Interviews with staff members, hospice company, and Resident
A revealed Resident A does have skin breakdown on her bottom due to Resident A’s request to sit in her recliner chair. The facility provides toileting assistance and frequent checks to assist in the healing of the skin breakdown. There is lack of evidence to support the allegation that Resident A is neglected at the facility.
CONCLUSION: VIOLATION NOT ESTABLISHED
ALLEGATION
:
Facility has insufficient staff. INVESTIGATION:
The complainant alleged the facility has insufficient staff and Resident A once had to wait 90 minutes for staff assistance. The complainant alleged the facility is severely short staffed and cannot assist in a timely manner.
Ms. Martin reported the facility is actively hiring to fill open positions. Ms. Martin reported every day the facility is using agency staff to cover open shifts. Ms. Martin reported caregivers are to answer call lights as quickly as possible. Ms. Martin reported caregivers do the best they can to address the resident needs.
On 2/17/21, I interviewed staffing coordinator Carrie Slager at the facility. Ms. Slager reported the facility staffs each floor for the number of residents on each floor. Ms. Slager reported on the second floor there are 23 residents. Ms. Slager reported the facility staffing levels are to have one medication technician and three aids for all shifts. Ms. Slager reported at times the facility will go below their desired staffing levels and on average this happens twice per week. Ms. Slager reported the facility does not have an on-call or mandation policy. Ms. Slager reported if an employee calls off for their shift, she will put a message on their internal system requesting for an employee to cover the shift. Ms. Slager she will request for an employee to stay over or come in early. Ms. Slager reported employees work together and will usually cover the open shift. Ms. Slager reported management can and will work the floor, if needed. Ms. Slager reported the facility is using agency staff and have been doing so for a year. Ms. Slager reported agency staff is at the facility every day. Ms. Slager reported the facility is currently hiring.
Ms. Taylor reported due to staffing levels sometimes residents are transferred using only one caregiver instead of two. Ms. Taylor reported caregivers do everything they can do to provide the best care to the residents.
Ms. Lewis reported some days there is not enough staff at the facility. Ms. Lewis reported caregivers do the best they can to provide good care to the residents. Resident A reported there is not enough staff at the facility to meet her needs. Resident A reported at times she must wait upwards of 30 minutes before a staff member will answer her call light. Resident A reported she has had a bathroom accident because staff did not respond timely.
On 2/17/21, I interviewed Resident B at the facility. Resident B reported at times she must wait upwards of 15 minutes before a staff member answers her call light. Resident B reported she has self-transferred herself to the bathroom because no staff were available to assist.
On 2/17/21, I interviewed Resident C at the facility. Resident C reported the facility has lack of staff, especially in the evening hours. Resident C reported at times she has had to wait upwards of 15 minutes before a staff member will answer her call light.
On 2/17/21, I interviewed Resident D at the facility. Resident D reported the facility needs more staff. Resident D reported she has to wait around 20-30 minutes before a staff member will answer her call light.
I reviewed the staff schedule for 1/31-2/13. On the following days, the staffing levels set by the facility were not met:
2/1: First shift did not have a medication technician 10:30a-3:00p; second shift had two resident assistants 2:30p-5:00p; third shift had two resident assistants.
2/2: Third shift had two resident assistants 2:30a-7:00a 2/3: Third shift had two resident assistants.
2/4: Third shift had two resident assistants 2:30a-7:00a 2/5: Third shift had no medication technician.
2/6: First shift had two resident assistants; Second shift had two resident assistants 2:30-6:30p
2/7: First shift had two resident assistants.
2/9: Third shift had two resident assistants 10:30p-2:30a 2/12: Second shift had two resident assistants 2:30-7:00 2/13: Third shift had one resident assistant.
I reviewed call light response times for Resident A for 1/31-2/17. Resident A pushed their call light 102 times. Response times exceeded 15 minutes on 19 occasions. I reviewed call light response times for Resident B for 2/1-2/19. Resident B pushed their call light 65 times. Response times exceeded 15 minutes on 16 occasions and one occasion the wait time exceed one hour.
I reviewed call light response times for Resident C for 2/1-2/19. Resident C pushed their call light 73 times. Response times exceeded 15 minutes on 7 occasions. I reviewed call light response times for Resident D for 2/1-2/19. Resident D pushed their call light 102 times. Response times exceeded 15 minutes on 25 occasions. It was noted that staff response times frequently exceed 7 minutes and regularly exceed 10 minutes.
APPLICABLE RULE
R 325.1931 Employees; general provisions.
(5) The home shall have adequate and sufficient staff on duty at all times who are awake, fully dressed, and capable of providing for resident needs consistent with the resident service plans
ANALYSIS: Based on interviews with staff members, interview with residents, call light response times, and staff schedule
it was determined that the facility does not have sufficient staff on duty by increased call light response times and staffing levels not met.
CONCLUSION: VIOLATION ESTABLISHED
ADDITIONAL FINDINGS: INVESTIGATION:
Resident A’s service plan read,
“Resident has a history of skin impairment requiring treatment prescribed by a
physician. Requires verbal or visual reminders to change position or relieve pressure.”
APPLICABLE RULE
R 325.1922 Admission and retention of residents.
(5) A home shall update each resident's service plan at least annually or if there is a significant change in the resident's care needs. Changes shall be communicated to the resident and his or her authorized representative, if any. ANALYSIS: Interviews with staff members revealed Resident A has skin
breakdown on her bottom that requires ointment to be applied. In addition, Resident A has a pressure relief cushion to assist in the healing of the skin breakdown. Resident A is also active with Faith Hospice. Resident A’s service plan omitted this
information.
CONCLUSION: VIOLATION ESTABLISHED
On 3/1/21, I conducted an exit conference with authorized representative Mary Martin by telephone.
IV. RECOMMENDATION
Contingent upon receipt of an acceptable corrective action plan, I recommend no change in the status of the license.
2/24/21 ________________________________________
Kimberly Horst
Licensing Staff Date
Approved By: 2/24/21 _______________________________________ Russell B. Misiak Area Manager Date