NERMONT
AGENCY OF HUMAN SERVICES

DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING

Division of Licensing and Protection
103 South Main Street

Waterbury, VT 05671?2306


VoicefTTY (802) 871 ?331 7

To Report Adult Abuse: (800) 564-1612
Fax (802) 871?3318

December 3, 2015

Ms. Mary Belanger, Manger

St Joseph's Residential Care Home
243 North Prospect Street
Burlington, VT 05401?1609

Dear Ms. Belanger:

Enclosed is a copy of your acceptable plans of correction for the survey conducted on
October 27, 2015. Please post this document in a prominent place in your facility.

We may follow?up to verify that substantial compliance has been achieved and maintained.? 'If
we find that your facility has failed to achieve or maintain substantial compliance, remedies .
may be imposed.

Sincerely,

.
(is. meal-MEN

Pamela M. Cota, RN
Licensing Chief

  

 

Disability and Aging Services Blind and Visually Impaired
Licensing and Protection Vocational Rehabilitation

 FROil?l- St Joseph Home Burl 8028045540 T-2-?il P00030005 F-584
PRINTED: 11/12/2015

 

 

 

 

 

 

 

 

. . . . FORM APPROVED
Division of LicenSInci and Protection - ..
STATEMENT OF . (x1) CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION NUMBER: COMPLETED
. A BUILDING.

0.155 3- WING - 1 0/27/2015
NAME OF PROVIDER 0R . STREETADDRESS, CITY. STATE. ZIP cons 
243 NORTH 
3T RESIDENTIAL CARE HOME
- - BURLINGTON, VT 05401 
iD SUMMARY STATEMENT OF DEFICIENCIES IO OF CORRECTION (X5)
PREFIX ivusT BE PRECEDED sv FULL pREFix (EACH ACTION SHOULD BE COMPLETE
REGULATORY OR 1.50 IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE

 



 

R100 Initial Comments: R100

An unannounced On s?ite survey Was Completed
by the Division of Licensing and ProtectiOn on
10/27/15; the survey was a follow Up to a survey
of 8/25/15 The following deficiency was found.

8?ng v. RESIDENT CARE AND HOME SERVICES R162

5.10 Medication Management

 

 

5.111s. Staff will not assist with or administer any 

. . . . To guard against admitting residents
medication, prescription or over-the-countet?

medications for which there is not a physician?s ?nth Incomplete phys1c1ans Orders, the 1
written, signed order and supporting diagnosis or 3035??th form 11111313 b5 completed by
problem statement in the resident's record. the nurse doing the admission and

. . . countersigned by the DNS prior to
$313 REQUIREMENT Is not met as eVIdenced admission. If any of the information
Based on staff interview and record review, the 13 the adm1ssmn ?flu 1,101;
home failed to assure that residents 000W ?ml the documentatmn 15 -

administered medications had Written signed complete. This form will be kept as

orders for 1 or 5 applicable residents in the part of the admission paperwork.
survey. (Resident Findings include: 
Per record review, Resident #5 was admitted to . Please see attached form 
the home on 8/25/15 and there Were no ad1111331011 
admission orders for medications and treatments

signed by the physician as of the date of sun/ey. .
10/27/15 The resident was receiving 2 routine - - 3

daily medications and a treatment to the foot Ruta PUC *1 131115
without signed orderS In the medical rsCOTd Per - \i?r
interview with the nurse, the physician failed to - -
provide written orders although s/he had been
contacted by telephone On 3 occasions. The Only
medication order that had been signed by the
physician was a telephone order for warfarin.

 

 

 

 

 

 

Division of Licensing and Protection .
LABORATORY OR REPRESENTATIVES SIGNATURE . TITLE (X5) DATE

Mun 5 .. 1<

STATE Fon?ivi' em - ?3011 . 

 

 

?Ii?243% ?18:28 FROlii- St Joseph Home Burl 8028845640 F-584

CHECKLIST

The following forms need to be completed or copies
provided PRIOR to admission.

Resident name:

 

Admission date:

 

INSURANCE CARDS-copies of front and back of all insurance Cards
COMPLETE AND SIGNED ORDERS: Yes Initials



EMERGENCY CONTACTINFORMATION: Yes Initials

RESIDENT PICTURE 2 COPIES: Yes Initials



COLST: Yes Initials

ADVANCED DIRECTIVES: Yes N0

MEDICAL RELEASE OF INFORMATION FORM: Yes Initials

LEVEL Ill ADMISSION APPROVAL SIGNED BY PHYSICIAN: Yes Initials
PRN STANDING MEDICATION ORDERS: Yes Initials

COMPLETED DIAGNOSIS LISTING: Yes Initials

IF INFORMATION IS NOT BY ON DATE ADMISSION,
ADMISSION WILL BE POSTPONED UNTIL ALL DOCUIVIENTATION IS COMPLETE.

Signature of nurse completing admission: Date:

Signature of DNS: Date: