A NERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING Division of Licensing and Protection HC 2 South, 280 State Drive Waterbury, VT 05671?2060 Survey and Certification Voice/TTY (802) 241?0480 Survey and Certification Fax (802) 2410343 Survey and Certification Reporting Line: (888) 700?5330 To Report Adult Abuse: (800) 5644 612 March 8, 2017 Ms. Mary Belanger, Manager 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 January 18, 2017. 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, Pamela M. Cota, RN Licensing Chief Developmental Disabilities Services Blind and Visually Impaired Licensing and Protection Vocational Rehabilitation PRINTED: sacs/2017 5410?. Medication v-lillanagement 5 10 If a resident requires medication administration; unlicensed staff may administer medications underthe following conditions: - (2) A registered nurse must delegate the responsibility forthe administration of speci?c medications to designated staff for designated residents This REQUIREMENT ?Is not met as evidenced by? Based on staff. interview the facility failed to provide evidence that all unlicensed staff only delegates the responsibility fer the administration of specific medications to. designated staff for designated residents- and the Licensed Practical Nurse- the Director of Nursing (DNS) Is the RN who is responsible Ior delegating medication administration The Is on vacation. at the time of? -5urvey.- There Is no? documentation administration has occurred administer medications when a registered nurse - Per interview with the facility Executive Director (ED) the Staff Develooment Coordinator (EDD), - available to reflect the delegation of medication Individualflle Fonrvi APPROVED Division of Licensing and Protection OF DEFICIENCIES 0(2) MULTIPLE consrnocnon (X3) DATESURVEY . AND PLAN OF CORRECTION IDENTIFICATION NUMBER. A. BUILDING: - conetereo . . .0155. Uil?lslzot? I NAME or: PROVIDER on SUPPLIER I STREETADDRESS cITv; cons .. 243 NORTH PROSPECT STREET - ST JOSEPH 8 RESIDENTIAL ICARE HOME BURLINGTON, VT. 05491 . . - - {Karo} STATEMENT oF DEFICIENCIES Io . Pnovroens PLAN OF connecnon Ixs) PREFIX DEFIcIehcv InusT BE PRECEDED av FULL IPREEIX {egos connective ACTION- snouLo BE COMPLETE REGULATORY on LSC TAG TO the APPROPRIATE DATE . .I . oEFIcIencyI I I . R100 Initial Comments: . R190 An unannounced re-licensure survey and complaint investigation was conducted by the Division of Licensing In Protection on Iii? a . To Clarify, all of our med techs are trained . -18l201? The regulatory deficiencies by our RN Staff Development Coordinator were dammed as i3 resultIof the Investigation. I and our DON as regulations requireStaff Deveio ment Coordinator rovides . RESIDENT-DARE AND-HOMESERVIDES Rise-I '3 hands on skills training, study guides and training in?services. .. There does exist a list of caregivers deemed proficient to pass medications signed by the DON. The regulations do not infer that the documentation by the delegate and the DON on an individual basis. Aforrn has been created to address this deficiency. It Is the plan to remedy the cited as follows: 1 Two hours (and more according to need) of classroom Instruction will be given. One heur will cover the pathology signs and of diabetes and treatment The g/Ix/ second hours will review the administration of the routes of medications,' I e. ear, oral nasal rectal, and vaginal 2. Followingthe classroom instruction I each delegate will have a return demonstration on administering insullns, eye, ear, nasal, oral rectal and vaginal medications with the DON. The competencies be documented for each I'or 1M (aft/I"! Division of Licensing and Protection OR PROVIDERISUPPLIER REPRESENTATIVES IRE STATE FORM 6 8895 i QLOFII TITLE - DATE 3hr lfcontlnualion Sheet 1 of6 PRINTED: 02/081201? FORM APPROVED .Division of Licensing and Protection STATEMENT OF c1Es (x1) (x2) MULTIPLE CONSTRUCTION (WESLELSSTITEVDEY AND PLAN OF CORRECTION NUMBER: BUILDING: - 0155 B. WING NAME OF PROVJDER DR SUPPLIER STREETADORESS. ZIP coOE 243 NORTH PROSPECT STREET BURLINGTON- VT 05401 - (X4) Io . SUMMARY STATEMENT DEFICIENCIES ?Ia . PROVIDERS PLAN OF (x5, 5.10 MedicatiOn-Management 5. 10d if aresid'entf'n'aqLIires medication administratiOn unliCensed staff may. administer - medications und?r the following conditions: The registered nLIrse must accept reaponsibility for the proper administration _of medications _and' Is responsible for: i. Teaching designated staff proper techniques for medication administration and providing appropriate information aboutthe resident's condition. relevant medications and potential side effects; ii. Establishing a process fOr routine communication with designated staff about the- resident?s condition and the effect of medications. as well as changes in medications; - Assessing the resident's condition and the need for any changes In medications; and- Monitoring .and evaluating the designated staff performance in carrying out the nurse's instructions This REQUIREMENT is not met as evidenced 'b Based on record review and staff interview the .. facility failed to assure that the RN did the teaching of deSignated staff regarding'proper . techniques for medicationadministration and providing appropriate information about the. resident?s condition relevant medications and potential side effects. Findings include: Per staff interviews'and record review the process for educating new staff being delegated . . - SHOULD BE COMPLETE EACH MUST BE REEOEDEO er PREFIX (EACH CORRECTIVE . PREFIX REGULATORY on?tsc INFORMATION) TAO . To THE APPROPRIATE TAG . . - - R465 Continued From page 1 12155 3. Annually, during the performance eval- uation process in June each Med Tech who Is up R165 RESIDENT HUME R155 to date on his/her training and testing will renew 88:1: .3 their delegation privileges with the DON and sign - . an individual statement to that effect. (See we will have this requirement prior to June as soon by each Med Tech In a position statement . . the role of the nurse in delegating nursing inter? ..- ventions it Is stated that ?different nurses may carry out the various steps of this process when a task is delegated to an assistive person. in this our Med Techs have received much of what they have gthat Is necessary for safe practice Henceforth the . EDON will be attentive to document the teaching Et time that regularly occurs. attached sample) To satisfy the current deficiency as the return demonstrations are accomplished published by the State Board of Nursing' In 2014 on 4. Auditing the medication pass has been an ongoing practice and will continue at _St. Joseph 5. The DON will implement these audits and the records Will be kept in the individual Med Tech files (See attached form) El- 5. St. Joseph?s has conducTe initial and refresher skill training oppor? tUnities to check and upgrade skill com? pentencies of nurses and Med Techs. We will continue this practice and docu? ment this to individual files so they at readily available for the State. F?Di?d?t? 6. Regular communications! meetings with the Med Techs and DON will be documented and placed In indi? . WE {sen Vidual files. Division of Licensing and Protection STATE FORM _aass It continualicn sheet 2 of 5 we, 1.. l? I Med?Tech (PCA) Medication Delegation Statement for Unlicensed Stat]c I, Dorothy Delaney, RN, Director of Nursing, for the St. Joseph Keryick Residence certify that has been delegated the medication administration responsibility by me on . has successfully completed his] her in~ house med tech training as evidenced by achieving a passing grade (80% or higher) on her Med Tech written exam and by passing the clinical competency skills observation (see Competency Checklist}. Dorothy Delaney, RN, DON Date Director of Nu rsing 1.19.2017 TMA Goggle Docs; St. Joseph?s Reeidentiai Care Home, 243 North Prospect Street, Buriington, Vt 05401 EENTT Med Tech Competency Name: Date: Passed Return Demonstration using proper technique for the following: Administration of: l=>Eye Drops l=>Nose Spray l=>Ear Drops I=>lnhaler E>lnhaler with Spacer Ei>l\lebulizer l=>Topical Treatments Passed Written Exam with a score of 35% of better 1. Reads and Follows a MARsorrectiy 2. Understands the 5 R?s of proper medication Administration noted as follows: EbRight Resident EbRight Medication Emight Dose E>Right Time l=>Right Route 3. Checks of an Order noted as follows: CDReads Order LPReads Order Label CDReads Before Putting Med Back. Proper Hand Sanitation Proper Use of Glories Signed Med Tech ?Date Signed Dorothy Delaney, RN, DON - Date \\192. 0.0. red\01 Loretta?KerwickWursingWi Med Tech Skills Check List. docx SJH 1.19.2017 SJH TMA Google D095 1119,9012 4f; mm 2e: metctertmq Meg memmte regimes g? DMSIONOFKINNEYDRUGS Met?cm item Fess Monitor Facility - Name Unit Date Time Criteria Cement Emerreet Cum meant Medication Cart Top (trawers are clean. is used and cleaned correctly ?ppiesauce etc; are coveredr dated. timed and spoon handkes are Ha?d was}: is available Medical reference book avaizable Procedure Wash hands icitiaily and as hrdicated Cheek MAR far ?rst Merl m] retrieve package Check for a?ergies Check to make sure label is the same as MAR Remembers 5 client rights Cheek dosage. time. and route Transfer medication in a medicatiuu cup. '3 point check: read Fabel before. during, and after met med. Nurse net mucking {hand?ng medication- Ideutify resident Med is given with adequate I waterffc oct Resident is 'obserVed swallowing, medication Nurse is abE'e to identify medicatians administered and is {mowtedgeabfe to side effects Meditation admie?straticn: AC5 QD. BID. TID. QED. HS Route (IM. IV. topical, rectal. vagina}. NC. P0) 15 done correctl)" Medication administered within? 60 minutes (before and after) scheduled time Medication {0 be crushed or not crushed Sign off medication on MAR or circle it is refused after attempted to retreat and return POLICIES AND Services for Nming Facilities 2006 American Sodety ochnsukmt Phamiaciszs and MED-PASS. Inc. 199 4g? Loretta Horne! St Joseph Kervieir Residence CHECMEST Medication Administration Assessment Competency Criteria: Demonstrate knowiedge of principies and Evaluator Evaluator Comments purpose of medication assistance. The PCA: Initials Score - 1. Demonstrates knowledge of the 5 of medication administration 2. Adheres to Standard Precautions/cleanses hands at beginning of process and as appropriate during medication administration 4. Validates medications to be administered with resident?s Medical Record (MAR) against medication in the bubble pacsz). Completes the (3) check expectation. Documents resident administration of medications on MAR. 4. Pro-p ours medications accurately, identi?es and validates resident prior to medication administration, and observes the resident ingest the medications. 5. Looks the med cart and never leaves cart unattended. Ensures that medication keys are secure at all ?mes. 6.1dentifies medication which have parameters, evaluates the data (BP, pulse, BS level etc prior to. administering- medication. 7. Accurately draws up/dials/administers insulin return demonstration. Explains the difference between long acting and short acting insulin, offers common names for insulin brands in each category to the trainer 8 Identi?es interventions to be made for an individual prior to adn?nistering (hypothetically) PRN medications per resident mitten plan. Accurately completes narcotic count per procedure. 10 Identi?es two ways to find out Why a particular medication is ordered for a resident Identi?es how to find the iikel side effects of a medication iswith? WWI .. - wait is a a. . SCORING: Mast attain a 24/30 on competency "checidist withont receiving a score at i (one) in any category Eta-Demonstrates competency and consistency 2-Demonsrrates with minimal prompting/ass1 stance i-chuires retraining/education We" 5512; a, it (printed name) is Competent to pass medications at the Loretto Home/St. Joseph Kervick Residence. PCA Signature: Date: Nurse/Evaluator Signature: Date: - Updated cans/15. 1/19/17 ma Google Docs Farm 13?; 6 Med~Tech (PCA) Medication Delegation Statement for un-licensed staff Revised 1/19/2017 t, Dorothy Delaney, RN, Director of Nursing for St. Joseph?s Residential Care Home/ Kervick Homes, certify that the following urn?licensed staff members have been delegated medication administration responsibilities by me, a licensed Registered Nurse. - NAME Rx insulin Dated: Dorothy Doianetr, no, Director of Nursing tech delegation statement - latestdocx 11/15f2016 TMA 1f19/17 LORETTO . PRINTED: 02.081201? FORM APPROVE Division of Licensing and Protection - - STATEMENT OF DEFICIENCIES on) PRoVioEersupenenrcuA (x2; MULTIPLE CONSTRUCTION DATE SURVEY AND PLAN OF CORRECTION NUMBER: A BUILDING, COMPLETED 0155 . s. WING 01!18!201'7 NAME OF PROVIDER OR SUPPLIER STREETADDRESS, STATE. ZIP CODE 243 NORTH PROSPECT STREET 8 . I JOSEPH 8 RESIDENTIAL CARE HOME BURLINGTON, VT 05491 . . {x4} 10 SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION 0(5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH ACTION SHOULD BE COMPLETE TAG REGULATORY on Lee TAG To THE DATE R165 Continued From page 2 R165 to administer medications is as follows: The new delagatee is provided with a self-study packet. The delagatee studies the information . and when s/he feels ready, takes a test to T0 5'3?er the 5511?me pattern does - evaluate the learning. According to an interview - not remain the same across all three with the SDC there is no face to face instruction . . . . . by the Registered Nurse regarding medication On day Shift? administration techniques, side effects, nursmg staff we have housekeeping, medication actions and D?L?hei? necessary dining, administrative and activity information, and that process is accomplished staff as well as the DON and entirely by self-study and exams. This information was provided and confirmed by administrator that provide additional the RN SDC and the ED ininterview on 1/1771? supervision, at2:45 PM. On evening shift we have afull-time 8?21? V. RESIDENT CARE AND HOME SERVICES R178 med tech, a full?time care giver and . - either an LPN or caregiver until 5.11 Staff Services 9:00pm as well as 2?3 dining staff until 6:00pm that provide additional 5.11.a There shall be sufficient number of i quali?ed personnel available at all times to provide necessary care, to maintain a safe and heaithy environment, and to assure prompt, supervision. We will add an additional caregiver on i appropriate action in cases of injury, illness, ?re 5 day Shift during the times that i or other emergencies. . residents are receiving care and Eris REQUIREMENT IS not met as evidenced showers. Based on observation, record review, and staff i interviews the failed to assure that there We also continually revrevv our acurty are a sufficient number of qualified personnel and GUY staffing patterns as i, i aVaiIable at all times to provide necessary care, tot needed. 1' . i maintain a safe and healthy environment, and to assure prompt. appropriate action in cases of . - Additionally, we will program several injum illness, fire or other emergencies. Findings 5 of our remote doors to be alarmed l3 include: . . .- i 24/7? SI 8/ I 7 Per observation upon arrival at the faculity, there - ft!) is one direct Caregiver on duty with a Caregiverir i mil? Division of Licensing and ProteCtion . STATE FORM 5395 QLOF11 ?continuation sheet 3 of6 Division of Licensing and Protection PRINTED: 02i08f2017 FORM APPROVED Medication Technician also working. There was .. also a volunteer present. The staff explained that DNS is on vacation until the end of the month, the LPN, who lives in New York State, is scheduled to come in at noon and the Administrator is at a these residents are on 3 separate floors. The staffing pattern remains the same for all shifts. There are other staff who are about the during the day, during the week, including the DNS, a-volunteer who drives residents to appointments, housekeeping. dietary staff, and an activities person. In a review of the resident population, there are 16 residents with ERC (Enhanced Residential Care) variances. These variances are LOC (Level of Care) variances'that- indicate that the resident requires more care than usual for a resident of a Level 3 residence and that the facility has applied for a variance by attesting that the facility has adequate staff to meet the resident's needs. For each resident with ERC variance the facility must be prepared- to provide 1 hour per week of Nursing care per resident and 2 hours per day of Direct Caregiver care per resident. SinCe the staff state that'there is little actual care provided to most residents during the overnight hours, that would leave 32 additional hours per day of direct care to be covered almost entirely by the day and evening shifts in addition to the care required by the remaining 23 non-ERC residents. ,1 Additionally the residence has 7 doors accessible i to residents which are alarmed only during the,- 1 hours of 8 PM until 5 AM. The other 15 hours of the day these doors are not alarmed. There are i smokers who go out of the facility to smoke and there is, at least, one resident who has been identified as someone who wanders. meeting. There are 39 residents in the facility and - R178 STATEMENT OF DEFICIENCIES (X1) (X2) CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION NUMBER: A BUILDING COMPLETED . ,c 0155 a. WING 0111 mm 7 NAME OF PROVIDER DR - STREET ADDRESS. CITY. STATE, ZIP CODE 243 NORTH PROSPECT STREET ST RESIDENTIAL CARE HOME VT 05401 (x4) ID SUMMARY STATEMENT OF iD PLAN OF CORRECTION i (x5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX CORRECTIVE ACTION SHOULD BE 5 COMPLETE TAG REGULATORY OR 1.80 TAG CROSS-REFERENCED TO THE APPR OPRIATE DATE - DEFICIENCY) R178 Continued From, page 3 i Division of Licensing and Protection STATE FORM 6899 QLOFH if continuation sheet 4 of6 PRINTED: 03082017 FORM APPROVED Division Of Licensing and Protection STATEMENT OF DEFICIENCIES pm PROVIDERTSUPPUERICLIA MULTIPLE CONSTRUCTION (x3) OATE SURVEY AND PLAN OF CORRECTION NUMBER: A COMPLETED 0155 . 01i18i2017 NAME OF PROVIDER OR STREETAOORESS, STATE, ZIP CODE . 243 NORTH PROSPECT STREET ST JOSEPH 3 RESIDENTIAL CARE HOME BURLINGTON, VT 05401 (x4) iD SUMMARY STATEMENT OF - iD PLAN OF CORRECTION (X5) DEFICIENCY MUST BE BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC EDENTIFYING TAG CROSS-REFERENCED TO THE APPROPRIATE DATE . . DEFICIENCY). - Continued From page 4 - 3. i To clarity; we held 18 an in ervievvt ireCt aregivers atest at . . . tions s/he does do resident showers on the day shift (per state reguia f' and that some showers are done on the evening only4 are reqUIre Ire '5 shift. During the time when the caregiver is drills during 2016. We providing a shower, that leaves the Med Tech to held 5 at 10:00 am, 4 at a monitor all residents and administer any . medications needed. During the week the 3'30 pm, 4 at 5'00 am, additional staff may be available to assist at 1 at 2100 Pm: 1 at 2'45 times. On the weekend the staffing is 1 Med Tech pm, 1 at 3:00 pm, 1 at and 1_direct Caregiver on each shift. In an 4:00 am, and 1 at 5:30 interview the ED and the LPN both confirmed the nducted our staffing to be as described and the ED confirmed am. _e the number of ERC'residents to be correct as fire drills to correspond provided. with our shifts to - ensure proper training lX. PLANT R302 for staff and residents. . We did meet the spirit i 911 Disaster and Emergency Preparedness . 0f the bV conducting more than 9.11:0 Each home shall have in effect, and - the required avaiiabte to staff and resadents, written comes of f?re drills 1 a plan for the protection of all persons in the unannounce event Of fire and for the evacuation Of the building . on all three Shifts. i when necessary. All staff shalt be instructed . periodically and kept informed of their duties We are now under the plan. Fire driils shall be Conducted on unannounced fire drills 1 I at least a quarterly basis and shati rotate times of in the evenings. The i day among morning, afternoon, evening, and me director I night. The date and time of each drill and the - main ena 5! names Of participating staff members shall be wiil be for i Hdocumented coordinating the drills i i - and the administrator glam,? wiil review fire drill logs i This REQUIREMENT is not met as evidenced on a quarterly basis to 5 by: ensure compliance. Based on record review and staff interview the - Division of Licensing and Protection STATE FORM . sass li continuation Sheet 5 of 6 i {elm Division Of Licensing and Protection PRINTED: 021?081201? F0 RM APP facility failed to assure that annual fire drills rotate times Of day among morning, afternOOn, evening, and night. Findings include: Per record review the facility does hold six ?re drills annually however any fire drills held on the night shift were held between 4 AM and 5:30 AM, all fire drills on days were at 10 am, and all afternoon fire drills were held between 2 PM and 3:30 PM. There were no, fire drills between 3:30 PM and 4:00 AM. The facility failed to provide an evening ?re drill. The fire drills listed were con?rmed by the ED of the facility in interview on I the morning of 1213/17. I I i STATEMENT OF DEFICIENCIES PROWDERJSUPPLIERICUA 1x2) MULTIPLE CONSTRUCTION (X3) DATE suevev AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A COMPLETED 0155 5- 01:13:2017 NAME or PROVIDER OR suppose STREET AooREss. CITY. STATE, ZIP cone 243 NORTH PROSPECT STREET ST RESIDENTIAL CARE HOME BURLINGTON. VT 05401 {x4} in - SUMMARY STATEMENT OF i ID i PLAN OF CORRECTION {x5} paEFix (EACH DEFICIENCY MUST BE PRECEDED av FULL I my?; (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i 1 TO THE APPROPRIATE DATE i DEFICIENCY) R302 Continued From page 5 R302 Division Of Licensing and Protection STATE FORM 6393 QLOFH ?continuation sheet 6 or 6