STATE OF MICHIGAN
RICK SNYDER
GOVERNOR DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS LANSING
SHELLY EDGERTON DIRECTOR
611 W. OTTAWA • P.O. BOX 30664 • LANSING, MICHIGAN 48909
• June 15, 2018 Phyllis Williams 4979 Paw Trail Lansing, MI 48911 RE: License #: Investigation #: AS330337737 2018A0582016 Still Well AFC II
Dear Ms. Williams:
Attached is the Special Investigation Report for the above referenced facility. Due to the severity of the violations, disciplinary action against your license is recommended. You will be notified in writing of the department’s action and your options for resolution of this matter.
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) 284-9727.
Sincerely,
Derrick Britton, Licensing Consultant Bureau of Community and Health Systems 611 W. Ottawa Street
P.O. Box 30664 Lansing, MI 48909 (517) 284-9721 Enclosure
MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS
SPECIAL INVESTIGATION REPORT
I. IDENTIFYING INFORMATION
License #: AS330337737
Investigation #: 2018A0582016
Complaint Receipt Date: 03/07/2018
Investigation Initiation Date: 03/08/2018
Report Due Date: 05/06/2018
Licensee Name: Phyllis Williams
Licensee Address: 4979 Paw Trail
Lansing, MI 48911
Licensee Telephone #: (517) 394-1720
Administrator: Phyllis Williams
Licensee Designee: N/A
Name of Facility: Still Well AFC II
Facility Address: 3820 Jerree
Lansing, MI 48911
Facility Telephone #: (517) 749-4827
Original Issuance Date: 07/19/2013
License Status: REGULAR
Effective Date: 08/01/2017
Expiration Date: 07/31/2019
Capacity: 5
Program Type: DEVELOPMENTALLY DISABLED
MENTALLY ILL AGED
II. ALLEGATION(S)
III. METHODOLOGY
03/07/2018 Special Investigation Intake 2018A0582016
03/08/2018 Special Investigation Initiated - On Site At Still Well AFC II
04/20/2018 Inspection Completed-BCAL Sub. Non-Compliance 04/20/2018 Exit Conference
With Phyllis Williams, Licensee
ALLEGATION:
On 03/05/2018, direct care staff member Linda Leek was asleep while working at the facility during the day and was difficult to awaken. Ms. Leek displayed signs of confusion and an inability to function properly, leaving Resident B to answer the door.
INVESTIGATION:
I received this complaint on 03/07/2018. I initiated the investigation onsite at the facility on 03/08/2018. I interviewed Lori Leek, direct care staff member. Ms. Leek admitted to being asleep on the couch on 03/05/2018. Ms. Leek stated that Resident A was the only resident in the home at the time, as the other residents were at
school or day program. Ms. Leek stated that she dozed off a couple of times due to being exhausted. Ms. Leek stated that she was taking care of a sick relative during her time away from work, which left her very tired. Ms. Leek stated that Resident B’s case manager came to the facility, but she did not hear her at the door.Ms. Leek confirmed that Resident B answered the door for the case manager. Ms. Leek denied that she was under the influence of any prescription drugs, illegal drugs, or alcohol during her shift.
Violation Established?
On 03/05/2018, direct care staff member Linda Leek was asleep while working at the facility during the day and was difficult to awaken. Ms. Leek displayed signs of confusion and an inability to function properly, leaving Resident B to answer the door.
Yes
I interviewed Arthur Williams, husband of licensee Phyllis Williams, and direct care staff member of the facility. Mr. Williams stated that he was aware of Ms. Leek being asleep on 03/05/2018 while she was on shift in the middle of the day. Mr. Williams stated that he had questioned Ms. Leek about the incident, and Ms. Leek confirmed to him that she was asleep. Mr. Williams stated that this was the first time that he was aware of such an incident by Ms. Leek. Mr. Williams stated that he gave Ms. Leek a verbal warning and informed her that if she was found to be asleep during the work shift again, further action would be taken. Mr. Williams did not have any concern that Ms. Leek was under the influence of any substance at the time of this incident.
I was unable to interview Resident B, who passed away on 03/06/2018 as the result of a fatal car accident in which Ms. Leek was the driver. Information regarding this accident is found in Special Investigation #2018A0582017.
I reviewed the Assessment Plan for AFC Residents for Resident B, dated
12/12/2017. The assessment plan documents that Resident B required supervision while in the community, had limited verbal communication, was unable to read and write, required total hands-on assistance from staff with toileting, bathing, grooming, dressing, and personal hygiene. The assessment plan documented that staff
monitor, supervise, and give medications as prescribed.
Special investigation report number 2017A0783005, dated December 9, 2016, established a violation of Rule 400.14204 (2) after a staff member was employed part time at the facility, but due to her felony conviction of uttering and publishing she is not suitable to meet the physical, emotional, intellectual, and social needs of each resident. Licensee Phyliss Williams neglected to complete a criminal history check for the employee when she was re-hired. In a corrective action plan approved on January 5, 2017, the Mr. and Mrs. Williams documented that the employee was terminated as a household member and employee, effective December 2, 2016. On 04/20/2018 I conducted an Exit Conference with Phyllis Williams, Licensee.
APPLICABLE RULE
R 400.14204 Direct care staff; qualifications and training.
(2) Direct care staff shall possess all of the following qualifications:
(a) Be suitable to meet the physical, emotional, intellectual, and social needs of each resident.
ANALYSIS: Based on interviews with Ms. Leek and Mr. Williams, Ms. Leek admitted she was asleep while working her day shift at the facility. Ms. Leek admitted she was too tired to stay awake and did not hear Resident A’s CMH case manager arrive for a visit. Consequently, Ms. Leek was not aware that Resident A had allowed anyone to enter the facility and given her exhausted physical state could not meet the multiple needs of Resident B on that specific day.
CONCLUSION: REPEAT VIOLATION ESTABLISHED. [Reference SIR
#2017A0783005 dated 12/09/2016 and CAP approved 02/03/2017/15/09.]
APPLICABLE RULE
R 400.14303 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: Based on interviews with Ms. Leek, Mr. Williams, and the
assessment plan for Resident B, Ms. Leek did not have the capacity to provide personal care, supervision and protection of Resident B per his written assessment plan while she was asleep during her shift. The assessment plan documented that Resident B had various supervision needs, limited verbal
communication, and minimal safety skills. While Ms. Leeks was asleep, Resident B was left to answer the door at the facility when his case manager arrived leaving him vulnerable to whomever may have been at the door and to supervise himself in the facility while she was asleep.
CONCLUSION: VIOLATION ESTABLISHED
ADDITIONAL FINDINGS:
While at the facility, I heard a smoke detector constantly beeping, which indicated that the smoke detector is not working as designed. Mr. Williams and Ms. Leek were at the facility during this time and had not addressed this issue.
APPLICABLE RULE
R 400.14505 Smoke detection equipment; location; battery replacement;
testing, examination, and maintenance; spacing of detectors mounted on ceilings and walls; installation requirements for new construction, conversions and changes of category.
(3) The batteries of battery-operated smoke detectors shall be replaced in accordance with the recommendations of the smoke or heat detection equipment manufacturer.
ANALYSIS: Based on my observation of the beeping smoke detector while
at the facility, the battery in the smoke detector had not been replaced. The smoke detector continued to beep throughout the investigation.
CONCLUSION: VIOLATION ESTABLISHED
IV. RECOMMENDATION
On 06/07/2018, Special Investigation #2018A0582017 recommended revocation of the license and this recommendation remains.
. 06/07/2018 ________________________________________ Derrick Britton Licensing Consultant Date Approved By: 06/07/2018 ________________________________________ Dawn N. Timm Area Manager Date
