FREEDOM OF INFORMATION REPORT

Facility Information Audit Information

Permit: UL-0077 Audit Name: CRC GENERAL ROV 20161020
F a c i l i t y N a m e : ULCRCF-490 KOON STORE Type: L07 Investigation
ROAD-COLUMBIA Start Date: 03 Jul 2018 03:30 PM
Address: 490 KOON STORE RD End Date: 03 Jul 2018 06:15 PM
C i t y / S t a t e / Z i p : COLUMBIA, SC 29203-9573 Richland Inspector: JoMonica Taylor
Phone 2:
Fax:
Email:

                                       Overall Score                                      
                                    0.0%                                    

Report Notice
Question ID Question Answer
NOTICE01 Bureau of Health Facilities Licensing Report
2600 Bull St Notice
Columbia SC 29201-1708

REPORT NOTICE: If applicable, this Report of Visit includes a detailed description of the conditions, conduct or practices
that were found to be in violation of requirements. This inspection or investigation is not to be construed as a check of every
condition that may exist, nor does it relieve the licensee (owner) from the need to meet all applicable standards, regulations
and laws. The South Carolina Code of Laws requires this Department to establish and enforce basic standards for the
licensure (permitting), maintenance, and operation of health facilities and services to ensure the safe and adequate
treatment of persons served in this State. It also empowers the Department to require reports and make inspections and
investigations as considered necessary. Furthermore, the Code authorizes the Department to deny, suspend, or revoke
licenses (permits) or to assess a monetary penalty against a person or facility for (among other reasons), violating a
provision of law or departmental regulations or conduct or practices detrimental to the health or safety of patients, residents,
clients, or employees of a facility or service. If applicable to the type of report being made, the signature of the activity
representative indicates that all of the items cited were reviewed during the exit discussion. If this Report of Visit is
required by regulation to be made available in a conspicuous place in a public area within the facility, redaction of the
names of those individuals in the report is required as provided by Sections 44-7-310 and 44-7-315 of the S.C. Code of
Laws, 1976, as amended.

Comments
    •   Report of visit sent via certified mail, US mail & e-mail on 7/23/2018.

Administrator's Signature - Plan of Correction

Question ID Question Answer
SIGN01 PLAN OF CORRECTION - Administrators Certification: I certify that the attached plan of correction describes: POC
(1) the actions taken to correct each cited deficiency, REQUIRED
(2) the actions taken to prevent similar recurrences, and
(3) the actual or expected completion dates of those actions.
 PRINT NAME:__________________________________________________________________________

TITLE:_______________________________________________________________________________

SIGNATURE:___________________________________________________________________________

DATE:________________________________________

Any violations cited in this report of visit were observed at the time of the inspection.

The Administrator submits an electronic plan of correction by visiting the website http://www.scdhec.gov/Health
/FHPF/HealthFacilityRegulationsLicensing/HealthcareFacilityLicensing/CorrectionPlan/ and following the instructions
online.

Or the Administrator returns a copy of this report (original signature required) with description of corrective actions to:

SCDHEC, Bureau of Health Facilities Licensing, 2600 Bull St, Columbia, SC, 29201

Your response to this report must be received in our office by close of business (5:00 p.m.) no later than the date listed
below:

Comments
    •   S u b m i t t h e P l a n o f C o r r e c t i o n ( P O C ) o n l i n e n o l a t e r t h a n J u l y 2 6 , 2 0 1 8 .
The link for submission is http://www.scdhec.gov/Health
/FHPF/HealthFacilityRegulationsLicensing/HealthcareFacilityLicensing /CorrectionPlan/

Inspection Information
Question ID Question Answer
COMBO-LIC Inspection Includes Licensing: YES
COMBO-FOOD Inspection Includes Food/Sanitation: NO
COMBO-FLSC Inspection Includes Fire & Life Safety: NO
ONSITE Is this an On-Site Visit? YES
INSP Select the Type of Inspection to be Performed: CRCF
Investigation
COMPL-01 Section Team Log Number: Section
Comments Team Log
    •   C04035-18 Number

COMPL-03 Reason for Investigation: Reason for

Comments Investigation:
    •   On the victim reported that was assaulted by a home
health care worker employee by Miles Residential Care. As a result of my criminal
investigation, I am unable to prove that the health care worker assaulted
stated that was employed by Miles Residential Care to give in
home care. lives at stated that after the
incident, did not return to home and now works at the residential care center
located at 490 Koon Store Rd. A criminal history check of shows that has a
conviction for child neglect under the alias
has a drug conviction for possession of
marijuana 1oz or less or 10g or less of hash or cocaine in
Section 300 of DHEC Standards for Licensing In-Home Care providers (61-122) states that
an employee with convictions for abuse/neglect and/or drug related convictions within the
past 10 years is a violation. The owner of Miles Residential Care is Betty Miles. It is
unsure if Miles conducted a criminal history check on continues to work
for Miles at this time. There are concerns that due to past conviction for
abuse/neglect and behavior towards should not be employed in the
capacity of providing care to those who are vulnerable. DSS case worker
also responded to home on in reference to an investigation. When I
asked what the investigation was in relation to, informed me that it was
confidential even though I am law enforcement.
COMPL-04 What is the Source: Consumer
Complaint
COMPL-10 Date Agency (DHEC) Notified: Date Agency
Comments (DHEC)
    •   04/03/2018 Notified:

COMPL-05 Detailed Results of this Investigation: Detailed

Comments Results
    •   To investigate the complaint, 2 BHFL investigators along with 7 Richland County Sheriff
Officers, arrived at the facility located at 490 Koon Store Rd. at approximately 3:30p.m.
The investigators entered the facility and were met by an individual who identified themself
as a staff member (staff member A). Staff member A was informed of the purpose of the
visit and presented with a search warrant by Richland County Sherriff’s Department. The
owner (staff member B), of the home was not present at the time of the investigator’s
arrival and did not arrive until approximately 4:40p.m, accompanied by two other adults.

The home is a one story, partial brick home with beige siding and beige shutters at the
windows. There are 4 bedrooms in the home, and a common area with a bed in it. The
common area also contained 2 love seats, a TV, microwave oven and a piano with books
and clothing piled up and stored on it. Bedroom 1 contained 2 beds a small refrigerator and
a microwave oven. Bedroom 2 contained 3 beds, a loveseat 2 small refrigerators, a
wheelchair, a desk, a TV and a microwave oven. Bedroom 3 contained 3 beds, 3 chairs, 1
loveseat, 2 small refrigerator,2 microwave ovens and 1 TV.Bedroom 4 (staff member A’s
bedroom) had 1 bed, a window AC unit, and was cluttered with clothing, cat and dog food,
cleaning supplies, and insect spray.

Upon entry of the home, three residents were observed sitting in a room, located to the left
of the entry way, watching TV. A fourth resident was later located by a detective and
brought into the room. The fourth resident was found in a locked room located down the
hallway, near staff member B’s office.

Interviews were conducted with Residents A,B,C and D. Resident E was not present at the
facility during the investigation. The following was discussed:

1.Resident A stated they lived at the home for 8-9 years. Funds were managed by Staff
member B. Resident A stated that he/she takes about 12 different medications and that it
is administered by Staff members A or B. Medications with Resident A's name on them
were observed in several bags that were found in a locked room. Medications and MARs
for the month of July were delivered to the facility by mail from OmniCare of Spartanburg.
Resident A stated that he/she did not have access to the medication. Resident A’s
medications are stored in a locked room until they were administered by Staff member A or
B. Medications included: Alendromate Sodium Outer 70MG tablet. One tablet weekly.
Methotrexate 2.5MG tablet for methotrexate on one day each week, she is to take 4
tablets in the AM then 3 tablets at bedtime. Amlodipine Besylate 10 MG Tablet for Norvasc
1 Tablet(s) every morning. Folic Acid 1MG tablet, for folic acid, 4 tabs daily.
Hydroxychloroquine Sulgate F/C 200MG Tablet, for Plaquenil Take 2 tablets by mouth daily
Monday through Friday on Sat,Sun, Take only one tablet daily. Resident A stated that
he/she does not physically pay money to Staff member B but it is set up to go directly to
Staff B to pay for staying there. Resident A stated that if he/she needs something, Staff B
will purchase it or take him/her to the store. Resident A stated that Staff member B
provides transportation to medical appointments, makes medical appointments and the
meals are prepared by staff member A and the laundry is done by staff member A.
Resident A stated that he/she is independent for all ADLs.

2. Resident B lived at the home for about 3 1/2 years. Resident B is not sure who
manages his/her funds or how much is paid monthly to stay at the home. Resident B
stated that Staff member B makes arrangements for a physician to come to the home to
provide medical services. Resident B stated that he/she does not administer his/her
medications. The medications are kept in a locked room until they are administered by
Staff member A or B. Staff members A and B are the only ones with a key to this room.
Medications with Resident B's name on them were observed in several bags that were
found in a locked room of the house. Medications and MARs for the month of July were
delivered to the house via mail from Omnicare of Spartanburg..Resident B stated that the
meals are prepared by staff member A and laundry is done by staff member A. Resident B
stated that he/she is independent for all ADLs.

3. Resident C lived at the home for 5 years. Resident C is not sure who manages his/her
funds or how much is paid monthly to stay at the home. Resident C stated that Staff B
provides transportation to medical appointments and makes medical appointments.
Resident C stated that they take 2 different medications and that it is administered by
Staff Member A or B. Medications with Resident C's name on them were observed in
several bags that were found in a locked room of the house. Medications and MARs for the
month of July were delivered to the facility, via mail fromOmnicare of Spartanburg.
Resident C stated that he/she does not administer his/her medications. The medications
are kept locked in a room until they are administered by Staff member A or B. Staff
member A and B are the only ones with a key to this room. Resident C stated that the
meals are prepared by staff member A and laundry is done by staff member A. Resident C
stated that he/she is independent for all ADLs.

4.Resident D was unable to provide any information. While conducting the search of the
facility Resident D was found in a dark room located in the back of the house with the door
locked and curtains shut. According to an interview with Staff Member A, it was stated that
Resident D is placed in the room to calm down when Resident D becomes agitated and
causes a disruption in the house. Medications with Resident D's name on them were
observed in several bags that were found in a locked room of the house. Medications and
MARs for the month of July were delivered to the facility via mail from Omnicare of
Spartanburg. Resident did not have access to the medications in the locked office until
they were administered by Staff A or B. Staff member A stated that Resident D receives
assistance with ADLs from Staff Member A for bathing and showering.

5.Resident E – was not at the house. Staff member A stated that Resident E has a job and
was at work. It was stated that Resident E works in Columbia SC.

An interview was conducted with Staff Member A and the following was discussed:

Staff Member A stated that they work at the home located at 490 Koon Store Rd in
exchange for room and board. Staff Member stated that his/her duties includes, cooking,
cleaning, assisting with making physician appointment, and administering medications to
the residents. Staff Member A admitted to bathing, shaving, feeding and assisting with
other ADLs forResident F, because Resident F wasn’t capable
of doing anything for him/her self. Staff member A stated that assistance is provided to
Resident D with bathing and shaving, and that he/she provided supervision for Resident D
as needed. Staff member A confirmed that Staff B was responsible for transporting the
residents to their physician appointments except for Resident E who caught the bus. Staff
member B would make sure Resident E made it to the bus stop.

The Department was unable to obtain any signed lease or contracts for any of the
residents in the house. When asked if there were any resident records, Staff member A
 stated that he/she does not know anything about the paperwork and that the owner (Staff
Member B) handles all of that.

As a result of an investigation, the Department determined that the facility located at 490
Koon Store Road, Columbia SC, established, operated, maintained and/or represented
itself as a CRCF at without first obtaining a license from the Department, in violation of
S.C. Code Ann. Section 44-7-260(A)(6) and Regulation 61-84 Section 103.A.

A CRCF is a facility which offers room and board and which, unlike a boarding house,
provides/coordinates a degree of personal care in excess of 24 consecutive hours for two
or more persons, 18 years or older, not related to the owner(s) /operator(s)within the third
degree of consanguinity. See 7 S.C. Code Ann. Regs. 61-84§ 101.1.L Personal care
includes: assisting and /or directing residents with activities of daily living; being aware of
residents general whereabouts, although residents may travel independently in the
community; and monitoring of activities of residents while on the premises of the residence
to ensure his/her health, safety and well-being. See id.§101.MM.
Regulation 61-84 Section 103.A provides in part, " When it has been determined by the
Department that room, board, and a degree of personal care to two or more adults
unrelated to the owner is being provided at a location and the owner has not been issued a
license from the Department to provide such care, the owner shall cease operation
immediately and ensure the safety, health and well-being of the occupants."

Further in light of this alleged violation, please submit an acceptable written plan of
correction (POC) to the Department that is signed by the Owner(s)/Operator(s) by
Thursday July 26, 2018 which describes: (1) the actions taken to correct each cited
deficiency; (2) the actions taken to prevent recurrences (actual and similar); and (3) the
actual or expected completion dates of those actions See id §202.D

Please note the Department has authority to assess a monetary penalty against a person
or facility for violating S.C. Code Ann. Section 44-7-260(A)(6) and Regulation 61-84 Section
103.A. See S. C. Code Ann § 44-7-320 (A)(1)(a) and 7 S.C. Code Ann. Regs. 61-84 § 301.
Additionally, S.C. Ann. Section 44-7-340 provides:
Any person or facility violation any of the provisions of {the State Certification of Need and
Health Facility Li censure Act ( the CON and Licensure Act), S.C. Code Ann Sections
44-7-110, et seq.} or regulation under{the CON and Licensure Act}is guilty of a
misdemeanor and, upon conviction, must be fined not more one hundred dollars for the first
offense and not more than five thousand dollars for a subsequent offense. Each day's
violation after a first conviction constitutes a subsequent offense.

COMPL98 Is this an Unlicensed Facility/Activity Complaint? YES

COMPL-06 Has the Initial QI Review Been Completed? NO
VERIFY02 Is the Current Facility/Activity Administrator the same as the Administrator of Record? NO
Comments
    •   N/A

INSP04 Are there any other individuals accompanying the auditor for this visit? YES
Comments
    •   Vanessa Stafford- Field Manager for the Complaint Division

Record Retention
Question ID Question Answer
RETENTION DHEC 0282 (05/2010) AUDIT - [Records Retention Schedule #SBH-F&S-17] Retention