STATE OF MICHIGAN DEPARTMENT OF HUMAN SERVICES

Transcription

1 STATE OF MICHIGAN DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING JENNIFER M. GRANHOLM GOVERNOR ISMAEL AHMED DIRECTOR December 28, 2010 Michael Wilson Riversbend Rehabilitation Inc 3707 Katalin Ct. Bay City, MI RE: License #: Investigation #: AS A Baywood Dear Mr. Wilson: Attached is the Special Investigation Report for the above referenced facility. Due to the violations identified in the report, a written corrective action plan is required. The corrective action plan is due 15 days from the date of this letter and must include the following: How compliance with each rule will be achieved. Who is directly responsible for implementing the corrective action for each violation. Specific time frames for each violation as to when the correction will be completed or implemented. How continuing compliance will be maintained once compliance is achieved. The signature of the responsible party and a date. If you desire technical assistance in addressing these issues, please feel free to contact me. In any event, the corrective action plan is due within 15 days. Failure to submit an acceptable corrective action plan will result in disciplinary action. P.O. BOX LANSING, MICHIGAN (517)

2 Please review the enclosed documentation for accuracy and feel free to contact me with any questions. In the event that I am not available and you need to speak to someone immediately, please feel free to contact the local office at (989) Sincerely, Diane L Stier, Licensing Consultant Bureau of Children and Adult Licensing 1919 Parkland Drive Mt. Pleasant, MI (989) Enclosure P.O. BOX LANSING, MICHIGAN (517)

3 MICHIGAN DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING SPECIAL INVESTIGATION REPORT I. IDENTIFYING INFORMATION License #: Investigation #: AS A Complaint Receipt Date: 09/13/2010 Investigation Initiation Date: 09/14/2010 Report Due Date: 11/12/2010 Licensee Name: Licensee Address: Riversbend Rehabilitation Inc 3707 Katalin Ct. Bay City, MI Licensee Telephone #: (989) Administrator: Licensee Designee: Name of Facility: Facility Address: Michael Wilson, Designee Michael Wilson, Designee Baywood 4202 Arctic Drive Bay City, MI Facility Telephone #: (989) Original Issuance Date: 09/23/2003 License Status: REGULAR Effective Date: 03/22/2010 Expiration Date: 03/21/2012 Capacity: 6 Program Type: TRAUMATICALLY BRAIN INJURED DEVELOPMENTALLY DISABLED 1

4 II. ALLEGATION(S) Resident A is allowed to go to his parents house & smokes pot & also brings it back with him. Resident A tried to rape a female staff. This was not reported. Alleged unsafe environment for residents & staff. Resident A is unwilling to follow instructions & threatens staff. On 9/12/10 he locked himself into the office where record files & medications are stored. He broke exterior window & threatened to kill the worker. They took 2 pieces of rebar from him & he insinuated he had a knife but they did not find one. III. METHODOLOGY 09/13/2010 Special Investigation Intake 2010A /14/2010 Special Investigation Initiated - Telephone 09/15/2010 Referral - Protective Services 09/15/2010 Contact - Telephone call made Witness 09/16/2010 Contact - Telephone call received Witness 1 09/17/2010 Contact - Telephone call received Witness 09/17/2010 Contact - Telephone call received APS Worker 1 09/21/2010 Contact - Telephone call made APS 09/21/2010 Inspection Completed On-site Interviews, records 09/22/2010 Contact - Document Received from Licensee Designee 09/22/2010 Contact - Face to Face Licensee Designee interview 09/22/2010 Exit Conference 2

5 ALLEGATION: Resident A is allowed to go to his parents house & smokes pot & also brings it back with him. INVESTIGATION: The complainant alleged that Resident A goes to his parents home where he smokes marijuana, and that the resident then brings marijuana back to the facility where he also smokes it. The complainant alleged that notices have been posted in the home telling staff not to stop Resident A from this but to encourage him to move off facility property when smoking marijuana. Licensee Designee Michael Wilson said he had only heard of Resident A s use of marijuana, and denied that there had been any notice issued instructing staff to move the resident off the property to smoke. Home Manager 1 also denied that any statement had been issued to staff concerning Resident A s use of marijuana, nor had any staff reported Resident A using marijuana at the AFC home. This allegation is not specifically rule-related and was not investigated any further as part of this complaint. ALLEGATION: Resident A tried to rape a female staff. This was not reported. INVESTIGATION: The complainant further alleged that Resident A raped a female staff in August. I interviewed Former Staff 1; the staff person that the complainant alleged was raped. She reported that Resident A did chase her to her car as she was leaving the facility one day. Resident A was wearing only shoes and socks. Former Staff 1 denied that Resident A made any physical contact. Former Staff 1 said the incident did scare her, and she transferred to another of the licensee s facilities for work. This allegation is not specifically rule-related and was not investigated any further as part of this complaint. ALLEGATION: Alleged unsafe environment for residents & staff. Resident A is unwilling to follow instructions & threatens staff. On 9/12/10 he locked himself into the office where record files & medications are stored. He broke exterior window & threatened to kill the worker. They took 2 pieces of rebar from him & he insinuated he had a knife but they did not find one. INVESTIGATION: A complainant alleged that Resident A posed a threat to residents and staff at this facility. On or around 9/12/10, Resident A locked himself in the office, where he had potential access to resident files and medications. The complainant reported that Resident A refused to come out or let staff in. 3

6 Former Staff 2 reported that during the third shift on 9/12-9/13/10, he told Resident A to turn the TV off and go to bed at 11 PM, which is in the house rules. Resident A came into the office and sat in the manager s chair behind the desk and refused to leave the office when Former Staff 2 requested it. Former Staff 2 went into the living room to phone the on-call supervisor, and Resident A then locked the door to the office from the inside. The on-call supervisor told Former Staff 2 she would send another staff to the home, and told Former Staff 2 not to escalate the situation. When Staff 3 arrived at the facility to provide assistance, he tried to talk Resident A into opening the office door, and Resident A complied after about ½ hour. Former Staff 2 stated that when the got the door open, Resident A had two pieces of rebar in his hands. Resident A told Staff 3 that he was going to wait for Former Staff 2 to hit him and then he was going to hit Former Staff 2 with the rebar. Staff 3 got the rebar away from Resident A and Former Staff 2 entered the office, whereupon Resident A threatened to cut Former Staff 2 s throat and disembowel him. According to Resident A s written assessment plan, Resident A is to be provided 1:1 supervision. Home Manager 1 said he was informed about this incident. Home Manager 1 said part of the problem is that Resident A and Former Staff 2 simply do not like one another. When Former Staff 2 tried to take the remote control and turn off the TV, that pushed (Resident A s) buttons. Home Manager 1 said that what Resident A had in his hands was not rebar but were the posts for a horseshoes game. Home Manager 1 said he did not know why the posts had been left in the office and not put away. Licensee Designee Michael Wilson reported that Former Staff 2 was discharged prior to 9/22/10. Mr. Wilson reported that Resident A s needs are attended by oneto-one supervision and that Resident A had never harmed other residents. APPLICABLE RULE R Resident care; licensee responsibilities. (2) A licensee shall provide supervision, protection, and personal care as defined in the act and as specified in the resident's written assessment plan. 4

7 ANALYSIS: CONCLUSION: The licensee failed to provide supervision and protection as defined in the act and as specified in Resident A s written assessment plan when Resident A was allowed access to the office and was left alone in the office, and thereby giving him access to potential harmful medications and the horseshoe stakes. VIOLATION ESTABLISHED APPLICABLE RULE R Resident protection. (3) A resident shall be treated with dignity and his or her personal needs, including protection and safety, shall be attended to at all times in accordance with the provisions of the act. ANALYSIS: CONCLUSION: Resident A s need for protection and safety were not attended when Resident A was left unattended in the office and thereby had access to potential harmful medications and the horseshoe stakes. VIOLATION ESTABLISHED IV. RECOMMENDATION Pending receipt of an acceptable corrective action plan, I recommend continuation of the current status of the license of this AFC adult small group home (capacity 1-6). Diane L Stier Licensing Consultant December 28, 2010 Date Approved By: 12/28/2010 Gregory Rice Date Area Manager 5