Print Inspection: MJKH

The findings of the re-licensure survey, conducted 05/01/23 through 05/02/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 05/02/23, conducted on 08/23/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 05/02/23, conducted 12/08/23 are documented in this report.  It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to implement an Acuity-Based Staffing Tool (ABST) that met the regulation. Findings include, but are not limited to:

The ABST must address all the required activity of daily living for each resident and the amount of staff time per resident needed to provide care.

The facilities tool grouped residents and tasks, not addressing the residents individually.

The facilities tool generated one combined staffing plan for the Assisted Living Facility and Memory Care Community on campus.

The need to use an ABST that addressed all the activity of daily living for each resident, the amount of staff time needed to provide care identified by resident, and generated a staffing plan for each individual license, was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) on 05/01/23 and 05/02/23. They acknowledged the findings.

Caring Places Management (Caring Places) operates Chinook Place and utilizes its own ABST tool that is being developed in its own propietary softare.

Caring Places' home office is working to implement an ABST tool that meets the requirements of the rule, including determining staffing requirements and demonostrating that it is meeting those requirements.

Caring Places is already submitting reports to the department for other communities it operates and will submit written reports, on behalf of Chinook Place, to the department every two (2) weeks beginning 5/19/2023. The report will outlne progress of implementation of ABST, barriers, proposed remediation of barriers, timelines, etc.

Based on interview and record review, it was determined the facility failed to implement an Acuity-Based Staffing Tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to:

The ABST must address all the required activity of daily living for each resident and the amount of staff time per resident needed to provide care.

On 08/23/23 at 9:58 am, Staff 1 (Administrator) confirmed the facility's ABST was not in compliance with the rule. She also confirmed her corporate office was creating their own tool and it was being tried out in a "beta" community.

The need to use an ABST that addressed all the activity of daily living for each resident, the amount of staff time needed to provide care identified by resident, and generated a staffing plan for each individual license, was reviewed with Staff 1 on 08/23/23. She acknowledged the findings.

As mentioned in our previous Plan of Correction,Caring Places Management(Caring places) operates CHinook Place and utilizes its own ABST tool that is being developed in its own property software.Caring Places' home office has been working to implement an ABST tool that meets the requirements of rule, including determining staffing requirments.

Caring Places continues to send reports to the Department on behalf of Chinook Place every two(2) weeks. The report outlines the progess of implementation of the ABST, barriers,proposedremediation of barries,timeline,ect.

Date of alleged compliance is flux,while Caring Places works alongside the department in finalizing its tool and rolling out implementation with Chinook Place.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 361

see C 361