Print Inspection: Q2OX

Based on observation, interview and record review, conducted during a site visit on 10/22/24, it was confirmed the facility failed to ensure the service plan was reflective of resident needs and ensure the implementation of services for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

A review of Resident 1's service plan, dated 09/19/24, indicated:

* Resident 1 resided in Adams House

* Resident 1 was to be checked for incontinence management every two to three hours.

During an observation between 5:50 am and 10:22 am on 10/22/24, Resident 1 was not checked or changed.

A review of Resident 2's service plan dated 10/19/24, and a Temporary Service plan dated 09/20/24 indicated:

* Resident 2 resided in Hood house.

* Resident 2 was incontinent of bowel and bladder and care staff were to check Resident 2 every two to three hours and assist with incontinence care; and

* Resident 2 had refused cares and when that occurred and Resident 2 became combative, staff were to leave him/her alone, re-attempt after sometime, and "call for a change of face."

During an observation on 10/22/24, Resident 2 was toileted upon waking at 7:08 am. Resident 2 was not provided incontinence care again until 11:01 am.

During an interview on 10/22/24, Staff 4 (UW) stated s/he was not able to toilet Resident 2 consistent with his/her service plan because Staff 4 was working alone and was cooking, serving and cleaning up breakfast from 8:00 am to 10:30 am. Staff 4 also stated Resident 2 was having a good day, but if s/he were to become aggressive, Staff 4 would have to call an administrator or other management to provide the change of face due to no other staff in the house.

A review of Resident 3's service plan dated 09/27/24 revealed:

*Resident 3 resided in Hood house.

*Resident 3 required scheduled and as needed medications administered by the MT one time per day.

During an interview on 10/22/24, Staff 4 (UW) stated Resident 3 did not have any daily medications.

The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 10/22/24.

The facility failed to to ensure the service plans were reflective of residents needs and ensure the implementation of services.

Verbal plan of correction: Facility will begin staffing two people in each house as soon as possible. They will begin recruitment immediately and will begin contacting agency until they can hire someone effective 10/22/24. They stated that was the last facility on campus with only 1 UW working in each house on a shift and the other houses have 2 UWs.

Based on observation, interview, and record review, conducted during a site visit on 10/22/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident for 2 of 3 sampled residents (#s 1 and 2). Findings include, but are not limited to:

Adams and Hood Houses were separate and distinct homes with no shared entrance, each consisting of two floors.

A review of the posted staffing plan (undated) indicated the following:

* Adams House - 6:00 am-6:00 pm: one Universal Worker (UW);

* Hood House - 6:00 am-6:00 pm: one UW;

* Adams House - 6:00 pm-6:00 am: one UW;

* Hood House - 6:00 pm-6:00 am: one UW; and

* Campus Float: 6:00 pm-6:00 am: one UW.

1 UW were observed working in each house during night shift ending on 10/22/24 and day shift beginning on 10/22/24.

A review of the facility's schedule for 10/16/24 through 10/22/24 revealed the facility regulary staffed only one UW per shift in each house.

A review of Resident 1's service plan dated 09/19/24 and "Fire and Life Safety Education" dated 03/29/24 revealed:

*Resident 1 resided in Adams House.

*Resident 1 was to be checked for incontinence management every two to three hours; and

*Resident 1 was a two-person transfer out of bed in the event of an emergency evacuation.

During an observation between 5:50 am and 10:22 am on 10/22/24, Resident 1 was not checked for incontinence management.

In an interview on 10/22/24, Staff 6 (UW) stated Resident 1 was a two-person transfer out of bed.

A review of Resident 2's service plan dated 10/19/24, and a Temporary Service plan dated 09/20/24 indicated:

*Resident resided in Hood House

*Resident 2 was incontinent of bowel and bladder and care staff were to check Resident 2 every two to three hours and assist with incontinence care; and

*Resident 2 had refused cares and when that occurred and Resident 2 became combative, staff were to leave him/her alone, reattempt after sometime, and "call for a change of face."

During an observation on 10/22/24, Resident 2 was toileted upon waking at 7:08 am. Resident 2 was not provided incotinence care again until 11:01 am.

During an interview on 10/22/24, Staff 4 (UW) stated s/he was not able to toilet Resident 2 consistent with his/her service plan because Staff 4 was working alone and was cooking, serving and cleaning up breakfast from 8:00 am to 10:30 am. Staff 4 also stated Resident 2 was having a good day, but if s/he were to become aggressive, Staff 4 would have to call an administrator or other management to provide the "change of face" due to no other staff in facility being available.

In an interview on 10/22/24, Staff 6 stated in the event of an emergency, s/he would have to call a neighboring facility or call management for assistance.

During an interview on 10/22/24, Staff 4 stated in the event of an emergency, s/he would have to have call any management and/or help from other facilities on the campus. S/he further stated if there was a fire s/he would take the residents to the flagpole but s/he didn't know who specifically would monitor residents at the flagpole or in the house during an evacuation.

During an interview on 10/22/24, Staff 2 (Administrator) stated the facility used to have a "float" on day shift who worked in both Adams and Hood houses, but their last day was 09/15/24. He further stated residents had eloped from the facility on 10/07/24 and 10/14/24.

The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 10/22/24.

The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

Verbal plan of correction: Facility will begin staffing two people in each house as soon as possible. They will begin recruitment immediately and will begin contacting agency until they can hire someone effective 10/22/24. They stated that was the last facility with only 1 UW working in each house on a shift and the other houses have 2 UW.

Based on observation, interview, and record review, conducted during a site visit on 10/22/24, it was confirmed the facility failed to develop and maintain and Acuity-Based Staffing Tool (ABST) for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:

Adams and Hood Houses were separate and distinct homes with no shared entrance, each consisting of two floors.

A review of the posted staffing plan (undated) indicated the following:

* Adams House - 6:00 am-6:00 pm: one Universal Worker (UW);

* Hood House - 6:00 am-6:00 pm: one UW;

* Adams House - 6:00 pm-6:00 am: one UW;

* Hood House - 6:00 pm-6:00 am: one UW; and

* Campus Float: 6:00 pm-6:00 am: one UW.

1 UW was observed working in each house during night shift ending on 10/22/24 and day shift beginning on 10/22/24.

A review of Hood House's ABST revealed the need for the following care hours:

Day (6:00 am - 6:00 pm): 10.38 hours

Night (6:00 pm - 6:00 am): 6.87 hours

An observation of the morning meal in Hood house revealed breakfast service lasts from 8:00 am to 10:30 am which was cooked, served and cleaned up by a Universal Worker.

Interviews on 10/22/24 with Staff 4 (UW) revealed UWs are responsible for preparing, serving and cleaning up the morning meal and serving and cleaning up the noon and evening meals between 6:00 am and 6:00 pm. Staff 4 stated the tasks take about five hours total. Staff 4 stated in the event of an emergency, s/he would have to have call any management and/or help from other facilities on the campus. S/he further stated if there was a fire s/he would take the residents to the flagpole but s/he doesn't know who specifically would monitor residents at the flagpole or in the house during an evacuation.

A review of the Adams House's ABST revealed the need for the following care hours:

Day (6:00 am - 6:00 pm): 10.63 hours

Night (6:00 pm - 6:00 am): 6.72 hours

An observation of the morning meal on 10/22/24 revealed breakfast service lasts from 8:00 am to 10:30 am which was cooked, served and cleaned up by a Universal Worker.

A review of the facility's schedule for 10/16/24 through 10/22/24 revealed the facility regularly scheduled only one UW in each house per shift.

In an interview on 10/22/24, Staff 6 (UW) stated Resident 1, who resided in Adams house required the assistance of two people to transfer out of bed.

A review of Resident 1's "Fire and Life Safety Education," dated 03/29/24, indicated  the resident was a two-person transfer out of bed in the event of an emergency evacuation.

In an interview on 10/22/24, Staff 6 stated in the event of an emergency, s/he would have to call a neighboring facility or administration for assistance.

During an interview on 10/22/24, Staff 2 (Administrator) stated the facility used to have a "float" on day shift who worked in both Adams and Hood houses, but their last day was 09/15/24. He further stated residents had eloped from the facility on 10/07/24 and 10/14/24.

In an interview on 10/22/24 at 7:07 am, Staff 7 (UW) stated s/he floated to all facilities on campus during night shift, minus the Specific Needs Contract building, and that s/he helped with resident care, showers, and the delivery of supplies and food.

Staff 7 was not observed in the facility again after the interview.

After multiple requests on and before 10/22/24, an ODHS-approved float waiver was not provided.

A review of Resident 1's service plan, dated 09/19/24, and ABST profile revealed discrepancies in time for the following ADL:

* Grooming.

A review of Resident 2's service plan, dated 10/11/24, and ABST profile revealed discrepancies in time for the following ADLs:

* Monitoring behavioral symptoms; and

* Non-pharmacological interventions for behaviors.

A review of Resident 3's service plan, dated 09/27/24, and ABST profile revealed discrepancies in time for the following ADL:

* Monitoring behavioral conditions or symptoms.

The findings were reviewed with and acknowledged by Staff 1 (Campus Director) and Staff 2 (Administrator) on 10/22/24.

The facility failed to fully develop and maintain an Acuity-Based Staffing Tool.