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9/9/2015 Survey Tag 0006 Detail for:
Monday, February 24, 2020 8:38 AM

Survey Date: 9/9/2015

Regulation Number:0006, level B scope/severity

Regulation Title: Compliance with Chapter II General Lic Regs

Regulation Description: 1.101 (2) Assisted living residences, as defined herein, shall be in compliance with all applicable federal and state statutes and regulations, including but not limited to, the following: (b) 6 CCR 1011-1, Chapter II, pertaining to general licensure requirements.

Surveyor Findings:

Based upon record review and interviews, the facility failed to comply with the requirements set forth in 6 CCR 1011-1, Chapter II, 6.104. Specifically, the facility failed to ensure residents and their legal representatives participated in decisions regarding their care as required, affecting three of three residents (#2, #3, and former resident #1), who were visited by an outside agency provider for the purpose of assessment and treatment. (Cross refer to tag #P388) The findings:

Pursuant to 6 CCR 1011-1 Chapter II General Licensure Standards, 6.104 (1) the health care entity shall develop and implement a policy regarding patient rights. The policy shall ensure that each patient or, where appropriate, patient designated representative, has the right to: (a) participate in all decisions involving the patient's care or treatment.

The department received a complaint on 4/27/15, that the facility had allowed an outside agency mental health provider to assess former resident #1 and residents #2 and #3 for possible treatment without first consulting with the residents or their respective legal representatives.

During the onsite investigation the records of residents #1 - #3 were reviewed. There was no evidence found that the facility had contacted the legal representatives or had discussed the with the residents the option of services being provided by the mental health provider prior to a visit to the facility by the mental health provider on 2/19/15.

Records from the outside agency mental health provider were received by the department on 9/1/15, including an email to the provider from the administrator of record. The email read, "I have attached the insurance information for the residents that may benefit from your services. Please let me know who you will be able to see on Thursday the 19th (2/19/15) at 10am (sic) so I can have their information for you."

The outside agency mental health provider was interviewed on 9/2/15. He stated that he had been in communication with the facility administrator in an effort to provide services to residents who may benefit from his services. He stated that he was sent the above referenced email from the administrator of record on 2/13/15. The outside agency mental health provider stated he set up a meeting with the facility to conduct assessments of the three residents and to review their respective records. He stated that he interpreted the email from the administrator of record as a "green light" to go ahead and conduct the assessments.

During interviews conducted on 9/2/15 with the three residents' respective legal representatives, each was asked if the facility had discussed with them the possibility of their resident receiving services from the outside agency mental health provider. One family member, stated that s/he first became aware of the outside agency mental health provider when meeting him at the facility on 2/19/15, and had later been told by the administrator of record that the outside agency mental health provider had been at the facility only to market his services, and was not to have had contact with any of the residents.

The administrator of record stated on 9/8/15 she had obtained verbal permission from resident #2 and #3's respective legal representatives to go ahead with an assessment by the outside agency mental health provider. She stated she had not yet heard back from former resident #1's legal representative prior to 2/19/15. The administrator of record further stated she had not documented the conversations with the other legal representatives when she said she received verbal permission to set up the assessments, which took place on 2/19/15.

Facility Plan of Correction:

P006- Compliance with lic regs (Resident Rights) The management team at Briargate will be inserviced on contacting legal representatives for decisions involving the patient’s care or treatment on Nov 3, 2015 by the District Director of Operations (DDO) and District Director Clinical Services (DDCS). The Colorado Bill of Rights and Coordination of Services with Outside Agency policy will be reviewed with the management team at that time. The Health and Wellness Director or designee will document in resident file when the legal representative is contacted regarding changes in patient care or treatment. The DDO and DDCS will review resident records for documentation at routine site visits to monitor for compliance.

(1.How was the in-service with the management team documented?)
An in-service/training sign-in sheet will be provided to document that associates attended training, as well as a copy of the Resident Rights, attached to the sign-in sheet.

(2.How often will the monitoring during site visits be occurring and how will that monitoring be documented?)

Community site visits will be conducted bi-annually by the DDCS or DDO, unless it is needed sooner. The visit will be documented on the site visit form and legal documentation in chart.

Back to Survey Tag Summary for:

Colorado Department of Public Health and Environment
Health Facilities and Emergency Medical Services Division
4300 Cherry Creek Drive South
Denver CO 80246-1530
Email us or phone 303.692.2800 main

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