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13 | Licensing Program Analyst Michael Smith contacted the facility via telephone to close the 2 referenced allegations via telephone due to COVID-19 and pre-cautionary measures. LPA discussed the findings with Andrea Armstrong, Administrator.
The investigation revealed that the admissions agreement requires a written notice for an increase of fees. According to the complainant, the increase was over the phone and at no time was any written notice sent to the RP. This is confirmed by the lack of production of any written documentation by the facility of the increase. Admission agreement states in section 3 (pages 4 & 5) that a minimum of 60 days prior written notice will be provided to you of any change in the monthly fee. Additionally, it states that a written notice of a level of care rate increases shall be provided within 2 business days after providing services at the new level of care. Complainant stated that the facility verbally told her they were backdating the new charges approximately 3 months. Complainant only became aware of the change of condition 3 months post after the phone call. According to Greg Awrey and the nursing supervisor, the business office is responsible to provide the notice, but they are short staffed, as the person who is supposed to send out the notices is currently on an extended leave.
In summation, the facility did not follow the agreed upon terms in the written and signed admissions agreement. Facility did not issue or provide a written notice to the RP as required in the admissions agreement. LPA requested and was never provided the written notice that was sent to the RP. Based on this, the allegations in the complainant are SUBSTANTIATED.
As a result of this investigation, LPA finds the allegations that staff did not provide resident with a written notice of rate increase in a timely manner and facility did not notify the authorized representative of resident's change in level of care to be SUBSTANTIATED. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met.
The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6.
An exit interview was conducted with Andrea Armstrong, Administrator via telephone and a copy of this report will be provided to Andrea Armstrong, Administrator via United States Postal Service. Two copies will be sent to the facility, 1 is to be signed and returned to CCL and the other copy is to be retained by the facility.
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| Substantiated | Estimated Days of Completion: |
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Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
01/20/2021
Section Cited
CCR
87507(4) | 1
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7 | 87507-Admission Agreements-Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes.
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7 | Facility shall adhere to the admissions agreement and abide by the requirements set forth in it. This shall be effective immediately upon receipt of this deficiency.
***Deficiency cleared*** |
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14 | This requirement is not met as evidenced by: Based on the lack of written documentation, the licensee did not adhere to the requirement in the admission agreement. Based on this, facility is in violation of this section. This poses a potential health and safety risk to residents in care.
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Type B
01/20/2021
Section Cited
CCR
87466 | 1
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7 | 87466-Observation of the Resident-The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual | 1
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7 | Facility shall regularly observed for changes and abide by the requirements set forth in this section. This shall be effective immediately upon receipt of this deficiency.
***Deficiency cleared*** |
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14 | weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.
This requirement is not met as evidenced by: Based on the facility not notifying the responsible party for 3 months of a change of condition, the licensee did not adhere to the requirements in this section. This poses a potential health and safety risk to residents in care.
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