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25 | On 7/5/2023, Licensing Program Analysts (LPA) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20230616164015. LPA met with Care Coordinator and administrator and explained the purpose of the visit.
During the initial complaint visit on 6/21/2023, LPA was informed resident #1 (R1) was transferred to the hospital due to an incident, and the administrator provided a copy of the incident report (LIC624) stating that R1 was transferred to the hospital on 6/5/2023. However, the report did not indicate that the incident was reported to CCLD, and LTCO. In addition, there is no record at CCLD that this incident was reported by the facility.
During the course of the complaint investigation, LPA observed the facility was notified by Institute on Aging in May 2023 of R1's change in health condition. However, R1's needs and services plan was updated during LPA's visit on 6/21/2023. According to facility director, R1's needs and services plan should have been updated in May 2023 when facility was notified by Institute On Aging of R1's changes in health condition.
In addition, LPA observed R1's needs and services plan was not signed and dated by the resident, responsible party and facility representatives. LPA interviewed R1 who stated that he/she did not know what a needs and services plan was and he/she was not part of the care planning process.
Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC809D. Failure to correct the deficiencies may result in civil penalties.
This report is reviewed and discussed with care coordinator and administrator. a copy is provided and appeal rights. |
Deficiency Type
POC Due Date /
Section Number | DEFICIENCIES | PLAN OF CORRECTIONS(POCs) |
Type B
07/14/2023
Section Cited
CCR
87463(a)
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7 | 87463 Reappraisals..(a) The pre-admission appraisal shall be updated,.. The reappraisals shall document changes in the resident's physical,.... | 1
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7 | The administrator/ licensee will develop a plan to ensure resident's needs and service plans are current reflecting resident's needs and health condition. This plan shall include staff training. |
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14 | This requirement is not met as evidenced by R1 had a change in health condition and needs and services plan was not updated in a timely fashion which posed a potential health risks to resident in care. | 8
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14 | The administrator will provide a copy of the plan and a copy of the staff training record to CCL by the plan of correction due date of 7/14/2023. |
Type B
07/14/2023
Section Cited
CCR87468.2(a)(7)
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7 | 87468.2Additional Personal Rights of Residents in Privately Operated Facilities..(a)In addition to the rights listed in Section 87468.1,..(7) To fully participate in planning their care, including the right to attend and participate in meetings | 1
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7 | The administrator will review the regulation and develop a plan to ensure residents and/or responsible parties are part of the care planning process and the care plan shall be reviewed and signed by all required reviewers. |
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14 | or communications regarding care and services to be provided,..This requirement is not met as evidenced by R1's needs and services plan was updated on 6/21/2023, however, the signature page indicating it was reviewed by R1 was blank which posed a potential health risk to resident in care. | 8
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14 | The plan shall include staff education. The administrator will provide a copy of such plan and a copy of staff education record to CCL by the plan of correction due date of 7/14/2023. |