state of washington · february 17, 2016 page2 of10 plan of correction avondale country estate...

Completion DateLicense #: 404803

February 17, 2016

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AVONDALE COUNTRY ESTATEPlan of Correction

STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES

AGING AND LONG-TERM SUPPORT ADMINISTRATION20425 72nd Avenue S, Suite 400, Kent, WA 98032-2388

Statement of Deficiencies

Licensee: TWT LLC

Sonia Coleman, RN, MN, Licensor

From:

DSHS, Aging and Long-Term Support Administration

Residential Care Services, Region 2, Unit E

20425 72nd Avenue S, Suite 400

Kent, WA 98032-2388

(253)234-6033

You are required to be in compliance with all of the licensing laws and regulations at all times to

maintain your adult family home license.

The department has completed data collection for the unannounced on-site follow-up inspection

of: 2/11/2016

AVONDALE COUNTRY ESTATE

16400 AVONDALE RD NE

WOODINVILLE, WA 98072

As a result of the on-site follow-up inspection the department found that you are not in

compliance with the licensing laws and regulations as stated in the cited deficiencies in the

enclosed report.

I understand that to maintain an adult family home license I must be in compliance with all the

licensing laws and regulations at all times.

This document references the following SOD dated: July 6, 2015

The department staff that inspected the adult family home:

DateResidential Care Services

DateProvider (or Representative)


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Licensee: TWT LLC

WAC 388-76-10192 Liability insurance required Commercial general liability insurance

or business liability insurance coverage. The adult family home must have commercial

general liability insurance or business liability insurance that includes:

(1) Coverage for the acts and omissions of any employee and volunteer;

(2) Coverage for bodily injury, property damage, and contractual liability;

(3) Coverage for premises, operations, independent contractors, products-completed operations,

personal injury, advertising injury, and liability assumed under an insured contract; and(4) Minimum limits of:

(a) Each occurrence at five hundred thousand dollars; and

(b) General aggregate at one million dollars.

Based on observation, record review and interview, the Entity Representative/Provider (ERP),

failed to provide proof of commercial general liability insurance since 2014. This failure placed

6 of 6 residents (Resident #1, #2, #3, #4, #5 and #6) at risk for not receiving compensation for

bodily harm or damage to their properties. Findings included:

Observation, record review and interviews were conducted on 02/05/20/16 unless otherwise

noted.

Observation found 6 residents resided in the home. Review of the home's records revealed no

current or past commercial general liability insurance.

In interview, the resident care manager was asked for the the home's liability commercial

insurance. She searched for the document but could not find it. She said, "I think she keeps it."

She said Staff A must have it at her home. As of 02/11/2016 the documents were not received.

This is a repeated uncorrecte deficiency previously cited on 07/06/2015.

Attestation Statement

I hereby certify that I have reviewed this report and have taken or will take active measures

to correct this deficiency. By taking this action, AVONDALE COUNTRY ESTATE is or

will be in compliance with this law and / or regulation on (Date)________________ . In

addition, I will implement a system to monitor and ensure continued compliance with this

cited deficiency.

Provider (or Representative) Date

This requirement was not met as evidenced by:

WAC 388-76-10320 Resident record Content. The adult family home must ensure that

each resident record contains, at a minimum, the following information:(10) A current inventory of the resident's personal belongings dated and signed by:

(a) The resident; and

(b) The adult family home.


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Licensee: TWT LLC

Based on observation, interviews and record reviews, the Entity Representative/Provider (ERP)

failed to ensure 6 of 6 residents (#1, #2, #3, #4, #5 and #6) had current inventories of personal

belongings dated and signed by the residents or their representatives and the home. This failure

placed all residents at risk for losing their personal items. Findings included.

Observation, interviews and record reviews were conducted on 02/05/2016 unless otherwise

noted.

Obsevration found Resident #4 sitting the common area with other residents. was

.

Review of all residents' records revealed they did not have a current inventory of their personal

belongings dated and signed by the residents, their representatives and the home.

Interview with Resident #6's representative during the full inspection on 07/06/2015 found the

resident had furniture and pictures in bedrooms from home. also had clothing and

an assistive device.

In an interview, the resident care manager said she could not find the residents' personal

inventories in their records. The department did not receive any personal inventory documents as

of 02/17/2016.

This is a repeate uncorrected deficiency previously cited on 07/06/2015.






cited deficiency.



WAC 388-76-10355 Negotiated care plan. The adult family home must use the resident

assessment and preliminary care plan to develop a written negotiated care plan. The home

must ensure each resident's negotiated care plan includes:

(7) If needed, a plan to:

(a) Follow in case of a foreseeable crisis due to a resident's assessed needs;

Based on observations, interviews and record reviews, the Entity Representative/Provider (ERP)

failed to ensure 1 of 2 sampled resident's (#4's) negotiated care plan addressed critical



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Licensee: TWT LLC

copy of the negotiated care plan could be mailed to the resident's representative.






cited deficiency.


WAC 388-76-10380 Negotiated care plan Timing of reviews and revisions. The adult

family home must ensure that each resident's negotiated care plan is reviewed and revised

as follows:

(4) At least every twelve months.

Based on observation, record review and interview the Provider failed to ensure 1 of 2 sampled

residents (#4) negotiated care plan was revised yearly. This failure placed the resident at risk for

not having care needs identified and met.

Observation, interview and record reviews were conducted on 02/05/2016 unless otherwise

noted.

Resident #4 was observed sitting in the common area. was

and appeared to be napping.

During the full inspection on 07/06/2015, the resident's negotiated care plan was not available

for review. On the follow-up inspection, Resident #4's negotiated care plan was found in the

home. It was dated 08/25/2014. The signature page was not included.

There was no evidence the negotiated care plan was revised every twelve months. The revision

was six months past due.

The resident care manager was asked to find the signature page. She searched the resident's

record and said she could not find it. The Provider failed to revise the resident's negotiated care

plan every 12 months.



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Licensee: TWT LLC






cited deficiency.


WAC 388-76-10522 Resident rights Notice Policy on accepting medicaid as a payment

source. The adult family home must fully disclose the home's policy on accepting medicaid

payments. The policy must:

(1) Clearly state the circumstances under which the adult family home provides care for

medicaid eligible residents and for residents who become eligible for medicaid after admission;(2) Be provided both orally and in writing in a language that the resident understands;

(3) Be provided to prospective residents, before they are admitted to the home;

(4) Be provided to any current residents who were admitted before this requirement took effect

or who did not receive copies prior to admission;(5) Be written on a page that is separate from other documents and be written in a type font that

is at least fourteen point; and(6) Be signed and dated by the resident and be kept in the resident record after signature.

Based on record reviews and interviews the Entity Representative/Provider (ERP) failed to

ensure 6 of 6 residents (#1, #2, #3, #4, #5 and #6) had signed copies of the home's policy on

accepting and keeping Medicaid eligible resident in their records. This failure violated the

residents' rights to be informed of the home's policy on Medicaid and placed the residents at risk

for displacement should private pay convert to Medicaid. Findings included:

Record review and interview were conducted on 02/05/2016 unless otherwise noted.

The residents were not able to review and sign records but their representatives signed for them.

Record review revealed none of the 6 residents had a signed copy of the home's policy on

accepting Medicaid payment.

In interview, the resident care manager looked for the policy in each resident's records and said

she could not locate them. No records were received as of 02/17/2016.

This is a repeat uncorrected deficiency previously cited 07/06/2015.



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Licensee: TWT LLC






cited deficiency.


WAC 388-76-10530 Resident rights Notice of services. The adult family home must

provide each resident notice in writing and in a language the resident understands before

admission, and at least once every twenty-four months after admission of the:

(1) Services, items, and activities customarily available in the home or arranged for by the home

as permitted by the license;(2) Charges for those services, items, and activities including charges for services, items, and

activities not covered by the home's per diem rate or applicable public benefit programs; and(3) Rules of the home's operations.

Based on record reviews and interview, the Entity Representaive/Provider (ERP) failed to ensure

5 of 6 residents (#1, #2, #3, #4 and #6) notice of services were available for the department staff

to review. This failure placed the resident at risk for not receiving care agreed on. Findings

included:

Record reviews and interview were conducted on 02/05/2016 unless otherwise noted.

Record reviews revealed only Resident #5 had a signed admission contract/notice of services.

The other residents had no admission contract or notice of services in their records.

In interview, the resident care manager kept the documents in her business file in her home. This

was the same response from Staff A during the full inspection on 06/24/2015, when Staff A told

the Department staff she kept the residents' admission contracts in her home and that there was

nothing to hide in them.

This is a repeat uncorrected deficiency previously cited on 07/06/2015.



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Licensee: TWT LLC






cited deficiency.


WAC 388-76-10585 Resident rights Examination of inspection results.

(1) The adult family home must place the following documents in a visible location in a

common use area where they can be examined by residents, resident representatives, the

department and anyone interested without having to ask for them.(a) A copy of the most recent inspection report and related cover letter; and

Based on observation and interview, the Entity Representative/Provider (ERP) failed to ensure a

copy of the last inspection report was posted in the home. This failure prevented 6 of 6 residents

(#1, #2, #3, #4, #5 and #6), their representatives and potential residents from reviewing the

current inspection report. Findings included:

Observation, interview and record reviews were conducted on 02/05/2016 unless otherwise

noted.

Staff A was not present during the on-site follow up. The resident care manager and Staff B

were the only caregivers on duty. These two caregivers lived in the home and provided twenty-

four hour care. Staff A did not live in the home.

Observation during the environmental round found the 07/06/2015 full inspection report was not

posted in a visible location in a common used area. The 2014 full inspection report was posted.

When interviewed, the resident care manager said she thought the full report was posted. She

removed the 2014 full inspection from the wall where it was posted and searched for the 2015

inspection but could not find it. The resident care manager said Staff A had the document at her

home.



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Licensee: TWT LLC






cited deficiency.


WAC 388-112-0205 Who is required to complete continuing education training, and how

many hours of continuing education are required each year?(1) Adult family homes

(d) Continuing education must include one-half hour per year on safe food handling in adult

family homes described in RCW 70.128.250 .

Based on observation, record reviews and interview, the Entity Representative/Provider (ERP)

failed to ensure the food safety continuing education training for 1 of 4 caregivers (Staff A) was

taught by a certified trainer. This failure placed 6 of 6 residents at risk for food-borne illnesses.

Findings included:

Observation, interview and record review were conducted on 02/05/2016 unless otherwise noted.

Observation found Staff A was not on duty. Interview with the resident care manager found

Staff A worked in the home sometimes.

WAC 388-112-0205-1-d states: Continuing education must include one-half hour per year on

safe food handling in adult family homes described in RCW 70.128.250. This means that in

order for food safety training to qualify as continuing education the training must be taught by a

qualified continuing education instructor.

Review of Staff A's food safety records found she did not receive food safety training from a

certified continuing education instructor. Staff A signed her food safety certificate which was

dated 04/23/2015. When the resident care manager was interviewed, she said Staff A was not a

certified continuing educator.

This is a repeat uncorrected deficiency previously cited on 07/06/2015.



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cited deficiency.


state of washington · february 17, 2016 page2 of10 plan of correction avondale country estate...

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