Z 000 Initial Comments Z 000
The following deficiencies are the results of the relicensure survey conducted on November 5 and November 6, 2008, for the purpose of determining the facility's compliance with COMAR 10.07.14, Assisted Living Program regulations. Survey activities included a tour of the facility, the review of five (5) resident records, the review of nine (9) employee records, observations of resident care and staff practices, and interviews of employees and residents. In addition, facility policies and procedures and administrative records were reviewed.
The facility census at the time of the survey was forty eight (48) residents.
Z2040 .15 A3 .15 Assisted Living Manager
A. Qualifications. The assisted living manager shall at a minimum:
(3) Be free from active reportable air borne communicable disease, and be free from any impairment which would hinder the performance of assigned responsibilities, as evidenced by a physicians' statement;
This REQUIREMENT is not met as evidenced by:
Z2040
Based on employee record review, the facility failed to ensure that the ALM (Assisted Living Manager) be free from any impairment which would hinder the performance of assigned responsibilities, as evidenced by a physician's statement.
Findings include:
Employee record review revealed no documented evidence of a physician's statement for the ALM.
OHCQ
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
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Z2060 .15 A5 .15 Assisted Living Manager
A. Qualifications. The assisted living manager shall at a minimum:
(5) Be of good moral character as evidenced by three letters of reference which attest to the character of the individual;
This REQUIREMENT is not met as evidenced by:
Z2060
Based on administrative record review, the facility failed to ensure that the ALM's (Assisted Living Manager) employee record contained three letters of reference attesting to the character of the ALM.
Findings include:
Review of the ALM's employee record revealed that one (1) letter of reference was available for review.
Z2160 .16 .16 Alternate Assisted Living Manager
An alternate individual shall be available to assume the responsibilities described in Regulation .15C(4)--(8) of this chapter when the assisted living manager is not available. The alternate individual shall be 21 years old or older and meet the qualifications as set forth in Regulation .15A(2)--(8) of this chapter.
This REQUIREMENT is not met as evidenced by:
Z2160
Based on employee record review, the facility failed to ensure that the Alternate Assisted Living Manager (AALM) met the required qualifications of the position.
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Findings include:
Employee record review revealed no documented evidence of a physician's statement for the AALM.
Z2190 .17 B(3) .17 Other Staff--Qualifications
B. Qualifications of Other Staff. At a minimum, all other staff shall:
(3) Be free from active reportable communicable disease, and be free from any impairment which would hinder the performance of assigned responsibilities, as evidenced by a physician's statement;
This REQUIREMENT is not met as evidenced by:
Z2190
Employee record review and interview with the ALM revealed that there is insufficient evidence to support that all staff have freedom from any impairment which would hinder the performance of assigned responsibilities as evidenced by a physician's statement.
Findings include:
Review of Staff #1's, Staff #2's, Staff #3's and Staff #4's employee record reveal no
documentation of a physician's statement for these employees.
Z2310 .18 B1 .18 Service Plan
18 Service Plan.
B. The assisted living manager, or designee, shall ensure that:
(1) A written service plan or other documentation sufficiently recorded in the resident's record is
Z2310
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developed by staff, which at a minimum addresses:
(a) The services to be provided to the resident, which are based on the assessment of the resident,
(b) When and how often the services are to be provided, and
(c) How and by whom the services are to be provided;
This REQUIREMENT is not met as evidenced by:
Based on record review the facility failed to develop service plans that are based on the resident assessment and include all services to be provided to the resident.
Findings include:
The following are examples of the deficient practice.
1. Resident #1 has multiple diagnosis including insulin dependent diabetes, bipolar disorder, and high blood pressure. The resident's diagnosis of diabetes requires the resident to receive insulin administration and blood sugar monitoring. The service plan states the resident's blood sugar should be maintained in a therapeutic range. The service plan does not include parameters for monitoring the resident's blood sugar levels. No other information is included regarding the resident's diagnosis of diabetes.
2. Resident #5 has multiple diagnosis including diabetes, high blood pressure, GERD (gastric esophogeal reflux disease) and bipolar disorder. Review of the resident's service plan reveals the diagnoses of diabetes, high blood pressure and GERD are not addressed within the service plan.
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Z2650 .21 N3 .21 Medication Management
N. Safe Storage of Medication. The assisted living manager, or designee, shall ensure that: (3) The following documentation is maintained for all residents for whom medications are
administered, or who receive assistance in taking their medications as defined by Regulation .02B(4)(b) of this chapter:
(a) Name of the resident, (b) Name of the medication, (c) Reason for the medication, (d) Dose,
(e) Physician's or authorized prescriber's name, (f) Date of issuance,
(g) Expiration date, (h) Refill limits; and (i) Directions for use.
This REQUIREMENT is not met as evidenced by:
Z2650
Based on observation during the survey process, the facility failed to maintain complete
documentation of the medications administered to individual residents.
Findings include:
1. Review of Resident #1's Health Care Practicioner's Physical Assessment (HCPPA) form reveals the resident is allergic to the medications Haldol and Vasotec. The resident's current physician's order sheet states the resident has no known drug allergies.
2. Review of Resident #2's HCPPA form reveals the resident is allergic to penicillin and Thorazine. The resident annual assessment dated 3/25/08 lists the resident's allergies as only penicillin. 3. Review of the facility's current medication administration records (MAR) and interview with Staff #5 reveals the facility does not maintain a OHCQ
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signature sheet. Therefore the initials of the individual administering medications can not be identified.
Z3610 .35 A .35 Assist Rails.
.35 Assist Rails.
A. An assisted living program shall provide assist rails in stairways used by resident's and for all toilets, showers, and bathtubs used by residents unless, through a waiver request, the Department determines that the physical abilities of the residents make these devices unnecessary for resident safety.
This REQUIREMENT is not met as evidenced by:
Z3610
During a tour of the facility on 11-5-08, the facility failed to comply with COMAR regulation
10.07.14.35.A. The regulation refers to the requirement to have assist rails for all toilets, showers, and bathtubs used by residents.
Findings include:
Based on observation and interview with the ALM, the facility failed to provide assist rails within the residents' shower.
Observation of the shower room used by the male residents of the facility revealed the handicapped accessible shower area contained an assist rail. The remainder of the shower stalls in the shower area did not have assist rails.
