STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS LANSING

Transcription

1 RICK SNYDER GOVERNOR STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS LANSING SHELLY EDGERTON DIRECTOR March 7, Wayne Rd RE: License #: AS Wayne Road Dear : Attached is the Renewal Licensing Study Report for the facility referenced above. You have submitted an acceptable written corrective action plan addressing the violations cited in the report. To verify your implementation and compliance with this corrective action plan: You are to submit documentation of compliance. You are to submit a Statement of Correction. An on-site inspection will be conducted. Please contact me with any questions. In the event that I am not available and you need to speak to someone immediately, you may contact the local office at (616) Sincerely, Matthew Soderquist, Licensing Consultant Bureau of Community and Health Systems 931 S Otsego Ave Ste. 3 Gaylord, MI W. OTTAWA P.O. BOX LANSING, MICHIGAN

2 MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS BUREAU OF COMMUNITY AND HEALTH SYSTEMS RENEWAL INSPECTION REPORT I. IDENTIFYING INFORMATION License #: Licensee Name: Licensee Address: AS Wayne Rd Licensee Telephone #: Licensee/Licensee Designee: Administrator: Name of Facility: Facility Address: Jessie Hamid 1093 Wayne Road Facility Telephone #: (989) Original Issuance Date: 09/08/2016 Capacity: 6 Program Type: AGED DEVELOPMENTALLY DISABLED 2

3 II. METHODS OF INSPECTION Date of On-site Inspection(s): 03/02/2017 Date of Bureau of Fire Services Inspection if applicable: Date of Health Authority Inspection if applicable: Inspection Type: Interview and Observation Worksheet Combination Full Fire Safety No. of staff interviewed and/or observed 2 No. of residents interviewed and/or observed 6 No. of others interviewed Role: Medication pass / simulated pass observed? Yes No If no, explain. Medication(s) and medication record(s) reviewed? Yes No If no, explain. Resident funds and associated documents reviewed for at least one resident? Yes No If no, explain. Meal preparation / service observed? Yes No If no, explain. Fire drills reviewed? Yes No If no, explain. Fire safety equipment and practices observed? Yes No If no, explain. E-scores reviewed? (Special Certification Only) Yes No If no, explain. Water temperatures checked? Yes No If no, explain. Incident report follow-up? Yes No If no, explain. Corrective action plan compliance verified? Yes CAP date/s and rule/s: Number of excluded employees followed-up? Variances? Yes (please explain) No 3

4 III. DESCRIPTION OF FINDINGS & CONCLUSIONS This facility was found to be in non-compliance with the following rules: R Resident admission criteria; resident assessment plan; emergency admission; resident care agreement; physician's instructions; health care appraisal. (4) At the time of admission, and at least annually, a written assessment plan shall be completed with the resident or the resident's designated representative, the responsible agency, if applicable, and the licensee. A licensee shall maintain a copy of the resident's written assessment plan on file in the home. Written assessment plans were missing signature pages. R Bedrooms generally. (4) Interior doorways of bedrooms that are occupied by residents shall be equipped with a side-hinged, permanently mounted door that is equipped with positive-latching, nonlocking-against-egress hardware. Bedroom doors did not have non-locking-against-egress hardware. R Bedrooms generally. (7) Bedrooms shall have at least 1 easily openable window. Bedroom 5 window would not open. R Smoke detection equipment; location; battery replacement; testing, examination, and maintenance; spacing of detectors mounted on ceilings and walls; installation requirements for new construction, conversions and changes of category. (3) The batteries of battery-operated smoke detectors shall be replaced in accordance with the recommendations of the smoke or heat detection equipment manufacturer. 5/6 smoke detectors had batteries installed incorrectly. 4

5 A corrective action plan was requested and approved on 03/02/2017. It is expected that the corrective action plan be implemented within the specified time frames as outlined in the approved plan. A follow-up evaluation may be made to verify compliance. Should the corrections not be implemented in the specified time, it may be necessary to reevaluate the status of your license. IV. RECOMMENDATION I recommend issuance of a 2 year regular adult foster care license. 3/07/2017 Matthew Soderquist Date Licensing Consultant 5