RICK SNYDER GOVERNOR State of Michigan DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING MAURA D. CORRIGAN DIRECTOR February 15, 2013 Tristan Schramke The Lighthouse, Inc. PO Box 289 RE: License #: Investigation #: AM790071567 2013A0866016 Harbor Light Dear Mr. Schramke: Attached is the Special Investigation Report for the above referenced facility. Due to the violations identified in the report, a written corrective action plan was required. On 02/15/2013, you submitted an acceptable written corrective action plan. It is expected that the corrective action plan be implemented within the specified time frames as outlined in the approved plan. 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 (810) 787-7031. Sincerely, Mary T. Fischer, Licensing Consultant Bureau of Children and Adult Licensing 1509 Washington, Ste A Midland, MI 48640 (989) 293-6338 enclosure P.O. BOX 30650 LANSING, MICHIGAN 48909-8150 www.michigan.gov (517) 335-6124
MICHIGAN DEPARTMENT OF HUMAN SERVICES BUREAU OF CHILDREN AND ADULT LICENSING SPECIAL INVESTIGATION REPORT I. IDENTIFYING INFORMATION License #: Investigation #: AM790071567 2013A0866016 Complaint Receipt Date: 02/14/2013 Investigation Initiation Date: 02/15/2013 Report Due Date: 03/16/2013 Licensee Name: Licensee Address: The Lighthouse, Inc. 1655 East Caro Road Licensee Telephone #: (989) 673-2500 Administrator: Licensee Designee: Name of Facility: Facility Address: Dorothea Wilson, Designee Dorothea Wilson, Tristan Schramke, Connie Hart, and Matthew Dennis, Designee Harbor Light 1785 Hope Drive Facility Telephone #: (989) 673-0542 Original Issuance Date: 07/25/1996 License Status: REGULAR Effective Date: 01/13/2012 Expiration Date: 01/12/2014 Capacity: 8 Program Type: PHYSICALLY HANDICAPPED DEVELOPMENTALLY DISABLED TRAUMATICALLY BRAIN INJURED MENTALLY ILL AGED 1
II. ALLEGATION(S) Staff Chris Schuster did not treat Resident A with dignity or respect when he was verbally abusive to Resident A. III. METHODOLOGY 02/14/2013 Special Investigation Intake 2013A0866016 02/15/2013 Special Investigation Initiated - On Site Interviewed Licensee Designee and Staff. 02/15/2013 Inspection Completed-BCAL Sub. Compliance 02/15/2015 Contact - Telephone call made Tuscola APS 02/15/2013 Exit Conference with Tristan Schramke ALLEGATION: Staff Chris Schuster did not treat Resident A with dignity or respect when he was verbally abusive to Resident A. INVESTIGATION: On 2/14/13, I received an AFC Licensing Division Incident / Accident Report documenting that Staff Chris Schuster had verbally mistreating Resident A. On 2/15/13, I interviewed Staff Mitch Gomez at the Lighthouse Rehabilitation Center. Mr. Gomez reported that he was on the west wing of Harbor Light playing cards with some of the residents when Staff Brandon Swithhart came over and handed a shower bench to Staff Gomez and asked him to put the shower chair in the west side bathroom. Staff Gomez said the door was wide open to the Eastside of the duplex and he could see Staff Chris Schuster standing in the doorway of Resident A s bedroom. Staff Gomez said he heard raised voices and then saw and heard Staff Chris Schuster say, Shut up and take your medication! Staff Gomez said he went over to Resident A s bedroom immediately and gave the shower chair to Staff Schuster and asked him to take it to the West side bathroom, and Staff Gomez took over for Staff Schuster. Staff Gomez reported to Staff Brandon Swithhart what he had observed and heard Staff Schuster say to Resident A. On 2/15/13, I received a hand written testimony from Staff Brandon Swithhart. Staff Swithhart documented that Resident A was having an episode of hearing voices and complaining he wanted to have PRN medication. Staff Swithhart said he left Resident A s room to go to the medication room and was not present when the alleged incident of Staff Schuster verbally mistreating Resident A. Staff Swithhart did hear raised voices, but did not know what was being said. Staff Swithhart 2
documented that Staff Gomez came to him and informed him of the incident and Staff Swithhart then reported this allegation to the home supervisor at North Star. On 2/15/13, Staff Chris Schuster was interviewed at the Lighthouse Rehabilitation Center. Staff Schuster said he spoke with Tristan Schramke yesterday about the allegations and raising his voice toward Resident A. Staff Schuster said that this Resident has mumbling and crying episodes everyday and it is very difficult to understand him. Staff Schuster said that at times they have to be firm with Resident A to get his attention and to distract him from his behavior. Staff Schuster said he did raise his voice to speak over Resident A s mumbling and crying, but in his opinion he was not yelling at Resident A. Staff Schuster said that he said, What the hell are you upset about? Staff Schuster said that many of the staff use that kind of language, he is not the only one. Staff Schuster explained that he was present to back up Staff Brandon Swithhart who was attempting to pass a PRN medication and had asked Resident A, What is your problem? Staff Schuster said that Staff Brandon Swithhart finally firmly said to Resident A, What do you want! Staff Schuster reported that Resident A responded, I want a PRN medication. Staff Schuster said that Brandon Swithhart responded, Fine, that s what I needed to know. Thank you, I will go get you one. Staff Schuster was asked if he told Resident A, Shut up and take your medication, and Staff Schuster said he did not recall if he said that and that it all happened so quickly, he could not be sure. Tristan Schramke and I shared consultation with Staff Schuster about the use of inappropriate language when speaking to residents as well as raising his voice. On 2/15/13, Resident A was not interviewed for this investigation as he has a serious speech impediment and is difficult to understand. On 2/14/13, I called Tristan Schramke to schedule an investigation regarding verbal mistreatment of a resident and the lack of dignity and respect afforded to Resident A by Staff Schuster. Mr. Schramke said that Staff Schuster had been taken off the staff schedule until the investigation could be completed. Tristan Schramke said that he planned to at least give a serious written write up to staff Schuster and to send him for a three hour re-training in Recipient Rights. APPLICABLE RULE R 400.14304 Resident rights; licensee responsibilities. (1) Upon a resident's admission to the home, a licensee shall inform a resident or the resident's designated representative of, explain to the resident or the resident's designated representative, and provide to the resident or the resident's designated representative, a copy of all of the following resident rights: (o) The right to be treated with consideration and respect, with due recognition of personal dignity, individuality, and the 3
need for privacy. ANALYSIS: CONCLUSION: Resident A was not treated with dignity or respect when Staff Schuster raised his voice and yelled at him to Shut up and take his medication or What the hell are you upset about? VIOLATION ESTABLISHED APPLICABLE RULE R 400.14308 Resident behavior interventions prohibitions. (2) A licensee, direct care staff, the administrator, members of the household, volunteers who are under the direction of the licensee, employees, or any person who lives in the home shall not do any of the following: (f) Subject a resident to any of the following: (ii) Verbal abuse. ANALYSIS: CONCLUSION: Staff Schuster was verbally abusive when he raised his voice to Resident A and asked him What the hell are you upset about? Staff Gomez reported he heard Staff Schuster tell Resident A, Shut up and take your medicine! VIOLATION ESTABLISHED IV. RECOMMENDATION I recommend continuation of the current status of the license of this AFC adult medium group home (capacity 7-12). Mary T. Fischer Licensing Consultant 02/15/2013 Date Approved By: Mary E Holton Area Manager 02/15/2013 Date 4