Tres Marias Home Care

Allegation investigated: Resident sustained pressure injuries due to staff neglect. Staff are mismanaging resident's medication. Unqualified staff caring for residents. Staff are not able to effectively communicate with residents

Licensing Program Analyst, Amber Coleman (LPA) arrived at the Tres Marias Home Care facility unannounced to deliver the findings of the complaint. LPA was greeted by Administrator, Maria Aloro. LPA signed in and was provided a space to work. It is alleged that a resident in care sustained a pressure injury due to staff neglect. Interview with the hospice agency revealed denial that residents in care are neglected. The hospice agency provides staff and family training on how to provide care according to residents’ needs. Staff and the Hospice agency deny that the residents in care are neglected in any way. Additionally, LPA reviewed medical records and progress notes of both hospice and the facility itself. No records indicated or showed evidence of neglect. Records were consistent with information collected in the interviews. Please see LIC9099-C Unsubstantiated It is alleged that staff are mismanaging residents’ medications. LPA reviewed resident’s Medication Administration Records along with the Centrally Stored Medications List. There was no evidence that medications had been missed. The documents were consistent with one another. Staff and Hospice Agency both deny having any problems with medication management. According the Adult and Senior Duty Logs, there have been no recent incident reports of medication errors from the facility. It is alleged that unqualified staff are caring for residents. LPA conducted a record review of seven (7) staff files. 7 out of 7 staff files included proof of training which meets regulation. All staff members are provided their training upon their hire date and annually afterwards. On 5/26/22, the facility was approved to care for six (6) hospice residents. It is alleged that staff are not able to effectively communicate with residents. During the visit, LPA communicated with Maria and number of staff members present. LPA had no difficulty communicating with staff to make requests or obtain records. LPA observed staff communicate with residents in care with no difficulty. LPA also observed staff communicating with one another with no difficulty. Staff all deny that they have had any trouble communicating with residents in care. Based on observations, record reviews and interviews, these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with facility representative and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jun 14, 2023 · control 56-AS-20230517081536

Type of visit: Case Management - Deficiencies

Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Tres Marias Home Care Facility to conduct a Case Management visit unrelated to the complaint. LPA was greeted by Administrator, Maria Aloro and discussed the purpose of the visit. While reviewing resident files, LPA observed that a Physician's Report for a resident in care was out dated. LPA inquired about the outdated document. Administrator reported that the resident in care was on service with another agency and was not aware the document would still need to be kept up to date. LPA and Administrator discussed the document and regulation. Administrator expressed that she understood. Based on observations and interviews made during today’s visit, one (1) deficiency is being cited per Title 22, Division 6, of the California Code of Regulations CCR). An exit interview was conducted and a copy of this report, LIC 809D, and Appeal Rights were given to the Licensee.the state’s words, verbatim · CDSS document, Jun 14, 2023

From the deficiency page — Deficiency type: Type B · Section cited: HSC 87458(a) · Plan of correction due date: Jun 14, 2023

87458 Medical Assessment - (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. This requirement was not met as evidenced by: Based on observation and interviews, the licensee did not ensure resident in care had all documents as regulated which poses an potential Health and Safety risk to persons in care.the state’s words, verbatim · CDSS document, Jun 14, 2023

Plan of correction: Liensee Agrees to review the regulation for Medical Assessment and self certify that the regulation is understood by way of a LIC9098 Form. This form is to be completed, then submitted to Community Care Licensing Office within 7 days.

Type of visit: Required - 1 Year

Licensing Program Analyst, Amber Coleman (LPA) arrived at the Tres Marias Home Care Facility unannounced to conduct an Annual Inspection. LPA introduced self and stated the purpose of the visit. LPA signed in and was provided a space to work. The facility has 3 resident bedrooms, 1 staff room, 2 bathrooms, a kitchen, dining area, living room, attached garage, and backyard. LPA conducted a general overall inspection, which included, but was not limited to, the following: Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected resident bedrooms; they are each equipped with required furniture such as: mattresses, night stands, adequate storage space, and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean. Appliances were operating appropriately and included adequate paper and hand hygiene products. Resident's hygiene materials were located in a secure cabinet under the sink. LPA tested the water temperature of the kitchen faucet, which ranged at 105 to 114 degrees F. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Posters such as; the personal rights, infection control and disaster plans were posted in common areas throughout the facility. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents. The designated storage space for resident/staff files is a secure hallway closet. Medications were locked and inaccessible to residents. The facility had emergency and first aid kits readily available for residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents. Please see LIC809-C Food Service: Non-perishable and perishable food supply is sufficient for number of clients residing in the facility. Facility has a variety of food available for residents; according to the monthly food menu posted on the facility refrigerator. Dishes, cups, and utensils were also stored properly. Emergency food and water were also observed during the visit. Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department. Record Review: LPA reviewed 3 client files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 3 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Medications were audited at random and appeared to be dispensed appropriately by staff members. Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A Technical Violation is being issued due to a locked side gate, which was corrected during the visit. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.the state’s words, verbatim · CDSS document, Jun 14, 2023

The state marks this report as 2 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 6 Census (if any clients in care): 6 COVID Mitigation Plan discussed? Yess Method: Telephone call with CAB COMP II Participants: Administrator Maria Aloro Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Staff qualifications and responsibilities 3. Applicant and Administrator qualifications 4. Program policy: Abuse, admission agreement, medication management, reporting incidents to CCL, restricted & prohibited conditions 5. Grievances, Complaints, Community resources 6. Physical plant, food service 7. Application document review and technical assistance: Criminal record clearance, Health screening, Fire clearance, First Aid/CPR certificate, Administrator certificate, Financial verification, Pre-licensing inspection, Compliance history, Controlthe state’s words, verbatim · CDSS document, Apr 20, 2022