VERMONT 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 http://www.dail.vermont.gov Survey and Certification Voice/TTY (802) 241-0480 Survey and Certification Fax (802) 241-0343 Survey and Certification Reporting Line: (888) 700-5330 To Report Adult Abuse: (800) 564-1612 March 27, 2019 Mr. Chris Starace, Manager St Joseph's Residential Care Home 243 North Prospect Street Burlington, VT 05401-1609 Dear Mr. Starace: Enclosed is a copy of your acceptable plans of correction for the survey conducted on January 15, 2019. 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, C-4-yAL-W1, Pamela M. Cota, RN Licensing Chief Disability and Aging Services Licensing and Protection Blind and Visually Imparied Vocational Rehabilitation PRINTED: 01/28/2019 FORM APPROVED UIVISIOH 01 Lice( isil um in su r1 inekas is (XI) PROVIDERISUPPLIER/CMA STATEMENT OF DEFICIENCIES IDENTIFICATION NUMBER. AND RAN OF CORRECTION (X2) MULTIPLE CONSTRUCTION A_ BUILDING:. 0111512019 B. WING 0155 NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY. STATE ZIP CODE ST JOSEPH'S RESIDENTIAL CARE HOME 243 NORTH PROSPECT STREET BURLINGTON, 1/T 05401 VC4)113 PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED 10 TFIE APPROPRIATE DEFICIENCY) (G) COMPLETE CW15 R100 R100 Initial Comments: An onsite unannounced re-licensure survey was conducted on 1/15-16/2019 by the Division of Licensing & Protection. The following deficiencies were identified as a result of the survey: R179 V. RESIDENT CARE AND HOME SERVICES SS=E RiaSe. See. 0.44-taliteck f imi R179 5.11 Staff Services 5.11.b The home must ensure that staff demonstrate competency in the skills and techniques they are expected to perform before providing any direct care to residents. There be at least twelve (12) hours of,training each year for each staff person providing direct care to residents. The training must include, but is not limited to, the foilowing: (1) Resident rights; (2) Fire safety and emergency evacuation;. (3) Resident emergency response procedures, such as the Heimlich maneuver, accidents, police or ambulance contact and first aid; (4) Policies and procedures regarding mandatory reports of abuse, neglect and exploitation; (5) Respectful and effective interaction with residents; (6) Infection control measures, including but not limited to, handwashing, handling of linens, maintaining clean environments, blood borne pathogens and universal precautions; and (7) General supervision and care of residents. This REQUIREMENT is not met as evidenced by Based on record review and interviews the facility Division of Licensing and (*awn RS OR • ROVI LABORATORY E - r ii (X3) DATE SURVEY COMPLETED / • LIER, FLESENTATIVES SIGNATURE _ App.. • Ada- PI° (2_01 - 12313 pocs cauf4e4 ;I d'9 14.1)1',71.)eAl 1120,- 6 cnvr 'on PRINTED: 01/28/2019 FORM APPROVED Division Of Licensing and Protection STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xi) PROVIDEILSUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION B. WING 015.5 01115/2010 NAME OF PRCANDEIR OR SUPPLIER STILEETADDRESS, CITY, STATE. ZIP CODE ST JOSEPH'S RESIDENTIAL CARE HOME 243 NORTH PROSPECT STREET BURLINGTON, VT 05401 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFDC TAG (X3) DATE SURVEY COMPLETED A. 13UILDING: R179 Continued From page 1 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVEACTION SHOULD BE CROSS-REFERENCED TO THEAPPROPRIATE DEFICIENCY) (X5/ . COMPLETE DATE ' R179 failed to assure that at least twelve (12) hours of training each year for each staff person providing direct care to residents was provided. The • training must include, but is not limited to, the prescriber] seven (7) mandatory inservices and additional inservices applicable to residenth residing in the facility.. Findings intlude: , Per review of inservice records for five (5) randomly selected Staff, for the year 2018, the selected staff failed to complete the required mandatory inservices as follows-. (1) Resident Rights: 2 of 5 did not complete; (2) Fire Safety and Emergency evacuation: consisted of a brief review of 4 fire safety phraseS (PASS, RACE, Low and Go, & Stop, Drop & Roll). 3 completed this and 2 did not complete; (3) Resident emergency response procedures, such as the Heimlich maneuver;accidents, police or ambulance contact and first aid: 4 of 5 staff completed a review of the Heimlich Maneuver only; . . (4) Policies and procedures regarding mandatory reports of abuse, neglect and exploitation: 1 staff completed 4 did not (5) Respectful and effective interaction with residents: 2 staff completed 3 did not; (6) Infection control measures, including but not limited to, handwashing, handling of linens, maintaining clean environments, blood borne pathogens and universal precautions: 3 staff completed 2 did not; (7) General supervision and care of residents. No evidence of staff completing this inservice. . Addilionally there is no evidence found of the 12 hours of training, no information regarding how long the face to face inservices lasted, how self-studies time was determined, and how inservices regarding OSHA (Occupational & STATE FORM F50111 It continuation sheet 2 of 5 PRINTED: 01128/2019 FORM APPROVED Division or Licensing ana trotecoon STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XD PROVIDERISUPPUERCLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A_ BUILDING. 01/15/2019 13 WING 0155 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. ZIP CODE ST JOSEPH'S RESIDENTIAL CARE HOME 243 NORTH PROSPECT STREET BURLINGTON, VT 05401 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG R179 Continued From page 2 ID PREFIX TAG. (XI) DATE SURVEY COMPLETED PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVEACTION SHOULD BE CROSS-REFERENCED TO THEAPPROPRIATE DEFICIENCY) (0) I COMPLETE DATE , R179 Safety Health Administration) requirements, mosquito bites, a ruptured gas line, and tick bites might apply to the facility residenrs care. Per interview on 1/15119 at 130 PM the current Director of Nursing Services and Acting Administrator confirmed that there was no further information regarding the 2018 education and that the former educator has left the facility. R200 V. RESIDENT CARE AND HOME SERVICES R200 , SS=C .-, 5.15 Policies and Procedures Each home must have written policies and procedures that govern all services provided by the home. A copy shall be available at the home for review upon request. This REQUIREMENT is not met as evidenced by: Based on record review and interviews the facility failed to assure that there are written policies and procedures that govern all services provided by the home. Findings include: Per record review, the facility's policies were limited to largely administrative policies and there were not clinical policies and procedures to reflect all aspects of care provided to current residents. In an interview the Director of Nursing confirmed that a lack of clinical policies and procedures had been identified and policy development has begun_ R302 SS=D IX. PHYSICAL PLANT R302 9.11 Disaster and Emergency Preparedness Division of Licensing and Protection STATE FORM F5Q111 Of continual= sheet 3 of 5 PRINTED: 01/28/2019 FORM APPROVED Division of licensing STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OM PROVIDERISUPPLIERICUA INIaNTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A BUILDING: B. WING 0155 01/15/2019 NAME OF PROVIDER OR SUPPLER STREETADDRESS, CITY, STATE, ZIP CODE ST JOSEPH'S RESIDENTIAL CARE HOME 243 NORTH PROSPECT STREET BURLINGTON, VT 05401 (M) ID PREFIX TAG R302 SUMMARY STATEDENT OF oericrEpicies (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSO IDENTIFYING INFORMATION) Continued From page 3 ID PREFIX TAG (X3) DATE SURVEY COMPLETED PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE - R302 9.11.c Each home shall have in: effect, and available to staff and residents, written copies of a plan for the protection of all persons in the event of fire and for the evacuation of the buirdirm when necessary_ All staff shall be instructed periodically and kept inkUrried of their duties under the plan. Fire drills shall be conducted on at least a quarterly basis and shall rotate limes of day among morning, afternoon, evening, and night_ The date and time of each doll and the names of participating staff members shall be documented. This REQUIREMENT is not met as evidenced by: Based on record review the facility failed to assure that fire drifts for 2018 rotate times of day among morning, afternoon, evening, and night. Findings include: Per record review, the facility exceeded the requirement to do quarterly fire drills but the fire drills conducted in 2018 did not meet the requirements for rotating times of day. There were none conducted during the hours between 4 PM and 4 AM with the exception of one done at 1 am, evening hours were Occluded_ Additionally many drills are conducted within the same time frame. The Acting Administrator confirmed that the fire drills were conducted as listed and the the facility manager present in 2018 has left the position. R313 SS=B XL RESIDENT FUNDS AND PROPERTY R313 F50111 If cdntinuation sheet 4 of 5 PRINTED: 0112812019 FORM APPROVED Division of Licensing and Protection STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER (X2) MULTIPLE CONSTRUCTION A BUILDING: B_ WING 0155 01115/2019 NAME OF PROVIDER OR SUPPLIER STREETADDRF_SS, CITY, STATE, ZIP CODE ST JOSEPH'S RESIDENTIAL CARE ROME 243 NORTH PROSPECT STREET BURLINGTON, VT 05401 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG. R313 Continued From page 4 ID PRF_ED( TAG (X3) DATE SURVEY COMPLETED PROVIDERS RAN OF CORRECTION (EACH CORRECTIVE ACT ION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE R313 11.1, A resident's money and other valuables shall be in the control of the resident except where there is a guardian, attarney in fact (power of attorney), or representative payee who requests otherwise_ The home may manage the residenrs finances only upon the written request of the resident. There shall be a written agreement stating the assistance requested, the terms of same, the funds or property and persons involved. k ig ..., This REQUIREMENT is not met as evidenced by-. Based on staff intervieww the facility failed to assure that residents with financial assistance had in place a written request of the resideht or the responsible party staling the assistance requested, the terms of same, and the funds and persons involved for 3 of 5 selected resident& Findings include: Per interview on 1/15/2019 at 1:30 PM the Administrative Assistant (AA) stated that of the 6 residents chosen for review 5 residents received assistance with finances and that of those 5 residents, there were only 2 written agreements requesting that assistance and explaining the terms The AA is responsible for providing the quarterly statements and monitoring the debits and credits. ___,_ — _ STATE FORM - • -6899 If continuation sheet 5 of 5 Plan of Correction St. Joseph Residential Care Home Re-licensing Survey 01/15/19 The submission of this plan of correction does not imply agreement with existence of deficiency. It is submitted in the spirit of cooperation, to demonstrate our commitment to continued improvement in the quality of our residents' lives. R179: 5.11 Staff Services What action you will take to Correct the deficiency? Administrator and Director of Nursing will develop an in-service training calendar to ensure that staff have at least twelve (12) hours of training each year as identified in Regulation 5.11.b in the Vermont Residential Care Home Regulations. What measure will be put into place or systemic changes you will make to ensure that the deficient practice does not occur? The Manager will review the training progress of each staff member on no less than a quarterly basis to ensure that each staff person providing direct care to residents will receive at least twelve (12) hours of training each year as identified in Regulation 5.11.b in the Vermont Residential Care Home Regulations. How corrective actions will be monitored so deficient practice does not recur? The Administrator and Director of Nursing will monitor this practice to ensure that this deficiency will not reoccur. The dates corrective action will be completed: Calendar published by 3/11/19. R200: 5.15 Policies and Procedures What action you will take to correct the deficiency? St. Joseph's does have Nursing Policies and Procedures. However, the Administrator and the Director of Nursing will review and update with additional materials appropriate for Level Ill care. What measure will be put into place or systemic changes you will make to ensure that the deficient practice does not occur? Administrator and Director of Nursing will review information annually. How corrective actions will be monitored so deficient practice does not recur? Administrator and Director of Nursing will review information annually and make updates appropriate for Level Ill care. The dates corrective action will be completed: 4/5/19 R302: 9.11 Disaster and Emergency Preparedness What action you will take to Correct the deficiency? Administrator with the Maintenance Supervisor will develop a fire drill schedule. What measure will be put into place or systemic changes you will make to ensure that the deficient practice does not occur? Administrator will review fire drill log quarterly. How corrective actions will be monitored so deficient practice does not recur? The fire drill log will be updated by the Maintenance Supervisor and audited by the Administrator to ensure the required fire drills are rotated by times of day. January — Morning (between 7am — 12pm) March — Night (between 11pm — 7am) May - Evening (between 5pm — 10pm) June - Afternoon (between 12pm — 5pm) July — Morning (between 7am — 12pm) September — Night (between 11pm — 7am) November— Evening (between 5pm — 10pm) December — Afternoon (between 12pm — 5pm) The dates corrective action will be completed: Schedule complete by 3/11/19. R313: RESIDENT FUNDS AND PROPERTY, 11.1 What action you will take to Correct the deficiency? We have completed an audit of all resident files and have asked residents to complete documentation regarding resident funds. See attached form. What measure will be put into place or systemic changes you will make to ensure that the deficient practice does not occur? As part of the Admissions packet for a new resident, the attached form will be completed and put in resident's file. How corrective actions will be monitored so deficient practice does not recur? Administrator will confirm that the attached form has been completed by new residents. The dates corrective action will be completed: 3/11/19 St. Joseph Residential Care Home 243 No. Prospect St. Burlington, VT. 05401 802-864-0264 Resident Request for Petty Cash Spending Account Date: , request that St. Joseph's Home open and maintain a petty cash spending account for me. I am opening/verifying my account today with a deposit/balance of $ I understand that I or my legal representative may view my account at any time and that my funds will be kept separate from all other monies and will be available to me, upon reasonable request. Resident Signature: Legal Representative Signature: Facility Representative Signature: *A quarterly statement of the account will be provided.*