08/16/16, Rev 09/09/16, 03/06/18, 04/16/18 1

STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

Facility’s Name: Cachola Adult Residential Care Home

CHAPTER 100.1

Address: 98-314 Ponokaulike Street, Aiea, Hawaii 96701

Inspection Date: February 19, 2020 Annual

THIS PAGE MUST BE SUBMITTED WITH YOUR PLAN OF CORRECTION. IF IT IS NOT, YOUR PLAN OF CORRECTION WILL BE RETURNED TO YOU, UNREVIEWED.

YOUR PLAN OF CORRECTION MUST BE SUBMITTED WITHIN TEN (10) WORKING DAYS. IF IT IS NOT RECEIVED WITHIN TEN (10) DAYS, YOUR STATEMENT OF DEFICIENCIES WILL BE POSTED ONLINE,

WITHOUT YOUR RESPONSE.

2

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-13 Nutrition. (l) Special diets shall be provided for residents only as ordered by their physician or APRN. Only those Type I ARCHs licensed to provide special diets may admit residents requiring such diets.

FINDINGS Resident #1 - "NAS, chopped, thin liquids" admission diet ordered 4/25/19; the resident is receiving a regular diet. Regular menus posted. No special diet menu.

PART 1

DID YOU CORRECT THE DEFICIENCY?

USE THIS SPACE TO TELL US HOW YOU CORRECTED THE DEFICIENCY

3

RULES (CRITERIA) PLAN OF CORRECTION

Completion

Date §11-100.1-13 Nutrition. (l)

Special diets shall be provided for residents only as ordered by their physician or APRN. Only those Type I ARCHs licensed to provide special diets may admit residents requiring such diets.

FINDINGS Resident #1 - "NAS, chopped, thin liquids" admission diet ordered 4/25/19; the resident is receiving a regular diet. Regular menus posted. No special diet menu.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

4

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (e) All medications and supplements, such as vitamins, minerals, and formulas, shall be made available as ordered by a physician or APRN. FINDINGS Resident #1 - "levothyroxine" label noted: "Take on empty stomach. Do not take antacids, calcium or iron within 4 hours of taking this drug." The medication is taken at 8 a.m. with breakfast and with "calcium with vitamin D."

PART 1

DID YOU CORRECT THE DEFICIENCY?

USE THIS SPACE TO TELL US HOW YOU CORRECTED THE DEFICIENCY

5

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (e) All medications and supplements, such as vitamins, minerals, and formulas, shall be made available as ordered by a physician or APRN. FINDINGS Resident #1 - "levothyroxine" label noted: "Take on empty stomach. Do not take antacids, calcium or iron within 4 hours of taking this drug." The medication is taken at 8 a.m. with breakfast and with "calcium with vitamin D."

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

6

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (e) All medications and supplements, such as vitamins, minerals, and formulas, shall be made available as ordered by a physician or APRN. FINDINGS Resident #1 - "Start calcium & vitamin D" ordered 4/30/19 without the strength, dosage and frequency specified. Complete "calcium & vitamin D" order dated 12/6/19.

PART 1

Correcting the deficiency after-the-fact is not

practical/appropriate. For this deficiency, only a future

plan is required.

7

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (e) All medications and supplements, such as vitamins, minerals, and formulas, shall be made available as ordered by a physician or APRN. FINDINGS Resident #1 - "Start calcium & vitamin D" ordered 4/30/19 without the strength, dosage and frequency specified. Complete "calcium & vitamin D" order dated 12/6/19.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

8

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (g) All medication orders shall be reevaluated and signed by the physician or APRN every four months or as ordered by the physician or APRN, not to exceed one year. FINDINGS Resident #1 - "Ocuvite and lovastatin" were not updated 4/25/10 to 12/6/19; a period of 7 months.

PART 1

Correcting the deficiency after-the-fact is not

practical/appropriate. For this deficiency, only a future

plan is required.

9

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (g) All medication orders shall be reevaluated and signed by the physician or APRN every four months or as ordered by the physician or APRN, not to exceed one year. FINDINGS Resident #1 - "Ocuvite and lovastatin" were not updated 4/25/10 to 12/6/19; a period of 7 months.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

10

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (g) All medication orders shall be reevaluated and signed by the physician or APRN every four months or as ordered by the physician or APRN, not to exceed one year. FINDINGS Resident #1 - "calcium with vitamin D" was not updated 4/30/19 to 12/6/19; a period of 7 months.

PART 1

Correcting the deficiency after-the-fact is not

practical/appropriate. For this deficiency, only a future

plan is required.

11

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (g) All medication orders shall be reevaluated and signed by the physician or APRN every four months or as ordered by the physician or APRN, not to exceed one year. FINDINGS Resident #1 - "calcium with vitamin D" was not updated 4/30/19 to 12/6/19; a period of 7 months.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

12

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (h) All telephone and verbal orders for medication shall be recorded immediately on the physician's order sheet and written confirmation shall be obtained at the next physicians visit and not later than four months from the date of the verbal order for the medication. FINDINGS Resident #1 - "D/C levothyroxine 75 mcg" order of 6/7/19 was not countersigned by the physician at the next office visit or within four months.

PART 1

DID YOU CORRECT THE DEFICIENCY?

USE THIS SPACE TO TELL US HOW YOU CORRECTED THE DEFICIENCY

13

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (h) All telephone and verbal orders for medication shall be recorded immediately on the physician's order sheet and written confirmation shall be obtained at the next physicians visit and not later than four months from the date of the verbal order for the medication. FINDINGS Resident #1 - "D/C levothyroxine 75 mcg" order of 6/7/19 was not countersigned by the physician at the next office visit or within four months.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

14

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (l) There shall be an acceptable procedure to separately secure medication or dispose of discontinued medications. FINDINGS Resident #1 - "alendronate sodium" discontinued on 6/7/19 was with current medication.

PART 1

DID YOU CORRECT THE DEFICIENCY?

USE THIS SPACE TO TELL US HOW YOU CORRECTED THE DEFICIENCY

15

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-15 Medications. (l) There shall be an acceptable procedure to separately secure medication or dispose of discontinued medications. FINDINGS Resident #1 - "alendronate sodium" discontinued on 6/7/19 was with current medication.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

16

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-17 Records and reports. (b)(8) During residence, records shall include: Notation of visits and consultations made to resident by other professional personnel as requested by the resident or the resident's physician or APRN; FINDINGS Resident #1 - No notation of visits to the physician.

PART 1

Correcting the deficiency after-the-fact is not

practical/appropriate. For this deficiency, only a future

plan is required.

17

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-17 Records and reports. (b)(8) During residence, records shall include: Notation of visits and consultations made to resident by other professional personnel as requested by the resident or the resident's physician or APRN; FINDINGS Resident #1 - No notation of visits to the physician.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

18

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-17 Records and reports. (f)(1) General rules regarding records: All entries in the resident's record shall be written in black ink, or typewritten, shall be legible, dated, and signed by the individual making the entry; FINDINGS Resident #1 - Blue ink used in the resident record. Primary care giver wrote medication lists in blue ink on 6/7/19 and 12/6/19. Blue ink used on the February 2020 medication record.

PART 1

Correcting the deficiency after-the-fact is not

practical/appropriate. For this deficiency, only a future

plan is required.

19

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-17 Records and reports. (f)(1) General rules regarding records: All entries in the resident's record shall be written in black ink, or typewritten, shall be legible, dated, and signed by the individual making the entry; FINDINGS Resident #1 - Blue ink used in the resident record. Primary care giver wrote medication lists in blue ink on 6/7/19 and 12/6/19. Blue ink used on the February 2020 medication record.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

20

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-17 Records and reports. (g) All information contained in the resident's record shall be confidential. Written consent of the resident, or resident's guardian or surrogate, shall be required for the release of information to persons not otherwise authorized to receive it. Records shall be secured against loss, destruction, defacement, tampering, or use by unauthorized persons. There shall be written policies governing access to, duplication of, and release of any information from the resident's record. Records shall be readily accessible and available to authorized department personnel for the purpose of determining compliance with the provisions of this chapter. FINDINGS Resident #1 - Correction tape used on the general operational policy.

PART 1

Correcting the deficiency after-the-fact is not

practical/appropriate. For this deficiency, only a future

plan is required.

21

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-17 Records and reports. (g) All information contained in the resident's record shall be confidential. Written consent of the resident, or resident's guardian or surrogate, shall be required for the release of information to persons not otherwise authorized to receive it. Records shall be secured against loss, destruction, defacement, tampering, or use by unauthorized persons. There shall be written policies governing access to, duplication of, and release of any information from the resident's record. Records shall be readily accessible and available to authorized department personnel for the purpose of determining compliance with the provisions of this chapter. FINDINGS Resident #1 - Correction tape used on the general operational policy.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

22

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-17 Records and reports. (h)(1) Miscellaneous records: A permanent general register shall be maintained to record all admissions and discharges of residents; FINDINGS Resident #2 - The resident was not recorded on the permanent general register.

PART 1

DID YOU CORRECT THE DEFICIENCY?

USE THIS SPACE TO TELL US HOW YOU CORRECTED THE DEFICIENCY

23

RULES (CRITERIA) PLAN OF CORRECTION

Completion Date

§11-100.1-17 Records and reports. (h)(1) Miscellaneous records: A permanent general register shall be maintained to record all admissions and discharges of residents; FINDINGS Resident #2 - The resident was not recorded on the permanent general register.

PART 2

FUTURE PLAN

USE THIS SPACE TO EXPLAIN YOUR FUTURE PLAN: WHAT WILL YOU DO TO ENSURE THAT

IT DOESN’T HAPPEN AGAIN?

24

Licensee’s/Administrator’s Signature: _________________________________________

Print Name: __________________________________________

Date: __________________________________________