7-day Action Plan for Adult Mental Health Services Community-Based Living Arrangement Homes IMMEDIATE ACTION: First, to assess homes for health and safety. Secondly, to find out where in the hierarchy of state employees that the negligence occurred; investigate what actions occurred and did not occur in response to housing conditions. Cera CGP ‘© Failure of state staff to conduct proper activities required ‘* Determine if homes are safe for consumers. for certification? ‘+ Investigate caseworker submitted reports and compare to ‘+ Failure of state staff to conduct timely inspections? current assessment. ‘+ Failure of state staff to observe the problems? © Investigate supervisory comments in response to submitted Failure of state staff to properly report findings? reports. ‘+ Failure of state staff to properly sanction providers? © Investigate reports submitted in July 2017 and compare to LCB analysis of same homes. DATE DUE: ‘* Home assessments completed by Monday January 22, 2018. ‘© Initial review of data and information with preliminary results provided by Tuesday January 23, 2018. ‘* Root cause analysis completed by Friday January 26, 2018.30-day Corrective Action Plan for Adult Mental Health Services Community-Based Living Arrangement Homes PROBLEM: Controls for monitoring providers of communi iving arrangement (CBLA) services are not adequate to ensure the safety and welfare of adult mental health clients. Poorly performed home inspections by DPBH staff have resulted in undocumented deficiencies, lack of corrective action, and continued proliferation of unsafe and unsanitary conditions. Inadequate certification of providers and lack of proper review and assessment procedures has resulted in certification of providers unable to provide safe and sanitary conditions for the mental IMMEDIATE ACTION: Lead investigation within State, into where the negligence in the process begins — in the investigations, supervisory oversight in response to investigations or in training and competence with employees on the state level. ‘OVERALL CORRECTIVE ACTION: Must improve controls to ensure that DPBH effectively inspects CBLA homes and properly certifies CBLA providers. Pec eee oe Perey Perens Porenrs Prey Audit Report Staff Training Ceuse Standardized Corrective Action _Sanctions to be Toran Peet Peet cr ae roe ec ee aes Eriol eee es Bir Documentationon Create new Create tiered 2/9/18 onstaff Unsafe or documentation sanctions for implementation of Unsanitary outlining new ——_ infractions that policies and Practices. proceduresfor range from minimal procedures. Determine if itis corrective action infractions to major Pee eccccnr Poland aie to ensure inspections Mandatory training Bena cua eeu more appropriate for Documentation on and potential infractions resulting HCQCto regulate Medication sanctions. in suspension or homes. ‘Management revocation of Practices. certification. Correa pete) Documentation regarding overall Quality of Life. Pere Rene cn) See attached 2/2/18 Peace standardized Ceara) reporting andcd sees tec ra Develop procedures for ing corrective Patera provider and home, istained Peter ycae Bree els Re eet when CBLA providers CUS un CIRO It Bene Pearse) Pret eet ka Mean Ake Ley Cea Pere cise nt) Beret ics ates ear eeny rea) Aiea Case workers will no longer be Coordinate with DCES to implement specific training to investigators about policies and procedures rega inthe home. Staff members who are caregivers must proficiency training to communicate with clients. certification activities. Determine if inspection and certification duties should be shifted from caseworkers to staff located in Bureau of Health Care Quality & Compliance. Implement screening and mandatory requirements for language profici and physical when hiring new staff. Develop appropriate reviews and assessments done during inspection of the CBLA home and proper procedure for corrective action. process for implementation. 2/9/18 2/16/18 2/16/18 2/16/18Pee ieraenr) Peete te fe provider ene’ et ene) Bruce Nac Roca eta rd and regulations Review of current caregivers and deficiencies in providing adequate care. Review standards for proper certification of CBLA homes. AB 46 effective July 2/23/18 1, 2017 grants Division regulatory authority to perform quality assurance reviews, impose sanctions and issue, renew, deny or revoke certifications.