Residential Care Services Investigation Summary Report

Provider/Facility: UNITED ADULT FAMILY HOMES(687783)

Intake ID(s): 3353089

License/Cert. #: AF750200Investigator: Judie, Sharon Region/Unit: RCS Region 2/Unit G InvestigationDate(s):

06/26/201707/10/2017

through

Complainant Contact Date(s): 06/26/2017, 06/27/2017, 06/29/2017, 07/03/2017, 07/10/2017Allegations:The adult family home (AFH) failed to refund monies to the named resident's (NR) representative within thirty days after the NRpassed away.

Investigation Methods:Sample: Residents Observations: General AFH

environment.Interviews: Provider, persons not

affiliated with AFH.Record Reviews: AFH administrative

records, NR records

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Residential Care Services Investigation Summary Report

Allegation Summary:Observation found one resident and a caregiver (CG) in the common area and the Provider in the office space of the AFH.

All observation, interview and record review occurred on 06/30/2017, unless otherwise noted.

In interview, NR's representative stated she had received a Department letter dated 05/08/2017 which stated she had overpaidR#6's February monthly AFH service fee. The NR's representative said she contacted the Provider for the refund and theProvider sent her a text stating the check paid for February was a copay for the month of January. The representative stated shemailed two certified letters to the Provider on 05/18/2017 and 05/23/2017 to request a refund and has not heard back from theProvider or received a refund.

In interview, Provider stated he received a Department letter from financial services that the refund was due. The Provider saidhe sent a cashier's check to the Department on 06/06/2017. The Provider said he did not refund any monies to R#6'srepresentative.

Record review revealed a Department vendor/provider overpayment notice dated 03/21/2017. Further record review found acashier's check mailed by the Provider to the Department on 06/06/2017.

NR's record review found NR went to the hospital on /2017 and passed away in the hospital on /2017. Further recordreview on 06/28/2017 found a Department letter dated 05/08/2017. The letter stated NR's authorization was modified andauthorized a refund for "overpayment of client responsibility."

Unalleged Violation(s): Yes No

Conclusion /Action:

Failed Provider Practice Identified /Citation(s) Written

Failed Provider Practice Not Identified /No Citation Written

See Statement of Deficiencies dated 07/10/2017

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