State of Michigan DEPARTMENT OF HUMAN SERVICES May 17 ...

RICK SNYDER
GOVERNOR
State of Michigan
DEPARTMENT OF HUMAN SERVICES
BUREAU OF CHILDREN AND ADULT LICENSING
MAURA D. CORRIGAN
DIRECTOR
May 17, 2013
Chad Underlay
Hope Network Behavioral Health Services
PO Box 890
3075 Orchard Vista Drive
Grand Rapids, MI 49518-0890
RE: License #:
Investigation #:
AS410067880
2013A0355040
Breton Valley
Dear Mr. Underlay:
Attached is the Special Investigation Report for the above referenced facility. Due to
the violations identified in the report, a written corrective action plan is required. The
corrective action plan is due 15 days from the date of this letter and must include the
following:
• How compliance with each rule will be achieved.
• Who is directly responsible for implementing the corrective action for each
violation.
• Specific time frames for each violation as to when the correction will be
completed or implemented.
• How continuing compliance will be maintained once compliance is
achieved.
• The signature of the responsible party and a date.
If you desire technical assistance in addressing these issues, please contact me. In any
event, the corrective action plan is due within 15 days. Failure to submit an acceptable
corrective action plan will result in disciplinary action.
P.O. BOX 30650 • LANSING, MICHIGAN 48909-8150
www.michigan.gov • (517) 335-6124

Please review the enclosed documentation for accuracy and contact me with any
questions. In the event that I am not available and you need to speak to someone
immediately, please contact the local office at (616) 356-0100.
Sincerely,
Grant Sutton, Licensing Consultant
Bureau of Children and Adult Licensing
Unit 13, 7th Floor
350 Ottawa, NW
Grand Rapids, MI 49503
(616) 916-4437
enclosure

MICHIGAN DEPARTMENT OF HUMAN SERVICES
BUREAU OF CHILDREN AND ADULT LICENSING
SPECIAL INVESTIGATION REPORT
I. IDENTIFYING INFORMATION
License #:
Investigation #:
AS410067880
2013A0355040
Complaint Receipt Date: 05/02/2013
Investigation Initiation Date: 05/02/2013
Report Due Date: 07/01/2013
Licensee Name:
Hope Network Behavioral Health Services
Licensee Address: PO Box 890
3075 Orchard Vista Drive
Grand Rapids, MI 49518-0890
Licensee Telephone #: (616) 726-1998
Administrator:
Licensee Designee:
Name of Facility:
Facility Address:
Angie Putnum
Chad Underlay
Breton Valley
2451 Breton Road, SE
Grand Rapids, MI 49546-5627
Facility Telephone #: (616) 949-3813
Original Issuance Date: 09/28/1995
License Status:
REGULAR
Effective Date: 03/28/2012
Expiration Date: 03/27/2014
Capacity: 6
Program Type:
MENTALLY ILL
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II.
ALLEGATION(S)
• Staff 1 may have left Resident A in a urine soaked bed.
III.
METHODOLOGY
05/02/2013 Special Investigation Intake
2013A0355040
05/02/2013 Special Investigation Initiated - Telephone
network 180, Office of Recipient Rights
05/08/2013 Inspection Completed On-site
Reviewed Resident A's facility file; interviewed the administrator;
interviewed Staff 1 with union representative and interviewed Staff
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05/09/2013 Contact - Face to Face
Interviewed Staff 3, 4, & 5; Reviewed medication log(s) for
Resident A
05/09/2013 Inspection Completed-BCAL Sub. Compliance
05/14/2013 Contact - Telephone Call Made
Message left for licensee designee
05/14/2013 Exit Conference
Licensee designee
ALLEGATION:
Staff 1 may have left Resident A in a urine soaked bed.
INVESTIGATION:
On 05/08/2013, I conducted an on-site investigation at the facility regarding the
allegation that Staff Ruth Hunter may have left Resident A in a urine soaked bed.
The incident is alleged to have occurred on 04/22/2013. While on-site, I reviewed
Resident A’s facility file and interviewed the Administrator, Angie Putnam and staff
Ruth Hunter and staff Charles Whitfield.
Present in Resident A’s facility file is a current Assessment Plan which indicates
under “toileting” that Resident A requires staff to prompt her and to assist as
necessary. The Person Centered Plan indicates that Resident A requires prompts
for toileting (and for bathing & dressing). Information in the file states that Resident
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A can initiate going to the bathroom on her own if she needs to independently.
Resident A wears an adult Depends undergarment. Resident A is 79 years of age.
Staff Ruth Hunter stated that she worked a double shift on 04/22/2013. Ms. Hunter
stated that she worked with Resident A during both shifts. Ms. Hunter stated that
she typically works 2 nd shift but when she has worked the 1 st shift, she has observed
Resident getting up and using the restroom independently. Ms. Hunter stated that
on the date in question, Resident A did not want to get out of bed in the morning, but
did take her a.m. medications. Ms. Hunter stated that when staff Billie Heft came in
mid-morning to take another resident to an appointment, Ms. Hunter asked Ms. Heft
about Resident A not wanting to get up. Ms. Hunter stated that Ms. Heft reported
that sometimes Resident A just doesn’t want to get up in the morning and that is
okay. Ms. Hunter passed Resident A’s medications to her at noon, at dinner time,
and in the evening. Ms. Hunter stated that Resident A sat up each time Ms. Hunter
asked her to and took her medications without incident. Ms. Hunter stated that after
she took her medications, Resident A would lie back down, pull the covers over her
head, and ignore any further prompting either to get up or to join them for breakfast,
lunch, or dinner. Ms. Hunter stated that she came into Resident A’s room and
prompted Resident A to get up and use the bathroom, at least, 1-2 times between
each medication administration and Resident A ignored her. Ms. Hunter stated that
sometime near the end of the 1 st shift, she observed that Resident A was wet, but
again, Ms. Hunter stated that Resident A refused to get up and change or allow
herself to be changed. Ms. Hunter stated that Resident A’s behavior did not suggest
that Resident A was ill and that there was no evidence that Resident A was not
feeling well to explain not wanting to get up so Ms. Hunter did not feel that medical
follow up was necessary. Ms. Hunter stated that she believed it is Resident A’s right
to stay in bed if Resident A chose to do so. Ms. Hunter did not request assistance
from her co-worker, Charles Whitfield, who also worked the double shift. Ms. Hunter
stated that she communicated to one of the 3 rd shift staff, Sarah Bakri that Resident
A had taken her medications all day but had refused to get up and was wet as a
result. Aside from the applesauce that is used with Resident A’s medications, Ms.
Hunter indicated that Resident A did not eat all day.
Staff Charles Whitfield worked the double shift with Ms. Hunter on 04/22/2013 as
Ms. Hunter had stated. Mr. Whitfield stated that he typically will work with the men
at the facility and the female staff will assist the women. Mr. Whitfield stated that he
will certainly assist as needed, but it seems to work well the way the work is typically
divided up. Mr. Whitfield stated that Ms. Hunter had communicated that Resident A
would not get up but he was unaware that Resident A was wet. Mr. Whitfield stated
that in his experience, it is not unusual for Resident A to not want to get up in the
morning but occasionally staff will need to be more insistent.
Resident A was taking a nap during my on-site inspection and was therefore not
interviewed.
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On 05/09/2013, I conducted an on-site investigation at the facility and reviewed the
medication log(s) for Resident A. I also interviewed staff Billie Heft, staff Sarah
Bakri, and staff Rachel Alberda.
The medication log for Resident A indicates that all medications are to be passed
with applesauce to prevent Resident A from chewing medications and supplements.
Although Resident A is on a number of medications and supplements, there is
nothing currently prescribed that requires it be taken after or with a meal. The
medication log(s) stated that Resident A is to be prompted to use the bathroom after
each meal and/or as needed. The logs stated that during the night (3 rd shift),
Resident A is to be awakened and prompted to use the bathroom at midnight and 5
a.m. The medication log includes an order that indicates that if Resident A refuses
any meals, Resident A is to be given a Carnation Instant Breakfast. None was
documented as given by Ms. Hunter on 04/22/2013.
Staff Billie Heft stated that when she came in to take another resident to an
appointment on 04/22/2013, she did tell Ms. Hunter that sometimes Resident A likes
to sleep in and she allows Resident A to do so. Ms. Heft stated that she would
never let Resident A stay in bed all day, indicating that she would get Resident A up
by lunch time, at the latest. Ms. Heft communicated that belief that even though
there are no written instructions for staff to be more insistent with Resident A, it is
“common sense” to do so.
Staff Sarah Bakri described her interaction with Ms. Hunter at the beginning of the
3 rd shift on 04/22/2013 as Ms. Hunter had reported. Ms. Bakri stated that she did
find Resident A to be very wet and prompted Resident A to get up so that she could
be showered and her bed changed. Ms. Bakri stated that occasionally when
Resident A has an incident of incontinence, Resident A might urinate a great
quantity. Ms. Bakri stated that occasionally during the night when staff prompts
Resident A to get up to use the bathroom, Resident A will refuse so staff will come
back later and try again. Ms. Bakri stated that Resident A sometimes gets up in the
night on her own to use the bathroom or to indicate that her Depends is wet and
needs assistance to be changed. Ms. Bakri stated that while assisting Resident A
with her shower, she did not observe any redness, skin breakdown, sores, or related
issues to having been left in a wet Depends. Ms. Bakri stated that Resident A
appeared to be feeling fine but stated that Resident A was seen by her doctor the
following day and was diagnosed with a UTI.
Staff Rachel Alberda stated that she worked the 3 rd shift with Ms. Bakri on
04/22/2013. Ms. Alberda stated that she assisted Ms. Bakri in getting Resident A up
and changed her bedding while Ms. Bakri helped Resident A take a shower. Ms.
Alberda stated that Resident A got up at 5 a.m. and used the bathroom without
incident. Ms. Alberda stated that Resident A did not appear to be not feeling well as
if that is the case, Resident A will typically be up and pacing most of the night. Ms.
Alberda stated that if she couldn’t get Resident A up to use the bathroom at all, she
would have attempted to change Resident A’s Depends in bed, as needed. Ms.
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Alberda stated that if Resident A absolutely refused to get out of bed for an extended
period of time, even though it isn’t written anywhere to do so, she would have
contacted her supervisor for instructions.
Resident A was up and asking Ms. Heft for ‘candy’ when I was conducting my onsite.
Resident A ignored my greetings and does not appear to have the capacity to
offer information that would be useful to this investigation.
On 05/14/2013, I conducted by telephone an exit conference with the licensee
designee, Chad Underlay.
Mr. Underlay stated that even though no violation was cited regarding the allegation
made, he is working on developing a treatment sheet to clarify expectations on
assisting Resident A, in particular, and is reviewing the plans for all of the residents,
in general.
APPLICABLE RULE
R 400.14303 Resident care; licensee responsibilities.
(2) A licensee shall provide supervision, protection, and
personal care as defined in the act and as specified in the
resident's written assessment plan.
ANALYSIS:
Although Resident A had wet herself for what appears to be the
entire 2 nd shift on 04/22/2013, staff Ruth Hunter insists that she
believed Resident A refused to get out of bed. Ms. Hunter
stated that she believed it is Resident A’s right to stay in bed if
she chooses to do so.
There was nothing in Resident A’s Assessment or Person
Centered Plans to support that Ms. Hunter had not provided
personal care to Resident A as outlined in the plan(s).
CONCLUSION:
VIOLATION NOT ESTABLISHED
ADDITIONAL FINDINGS:
During the course of the investigation, I observed that while staff person Ruth Hunter
did give Resident A her medications, as prescribed, during the course of the day and
evening on 04/22/2013, Ms. Hunter did not follow the doctor’s orders that if Resident
A did refuse a meal, Resident A is to be given a Carnation Instant Breakfast.
5

INVESTIGATION:
On 05/08/2013, I interviewed staff Ruth Hunter at the facility in the presence of her
union representative. Ms. Hunter stated that although Resident A took her
medications, as prescribed, during the entire double shift that Ms. Hunter worked,
Resident A refused to get out of bed to use the bathroom and to have any meals.
On 08/09/2013, I reviewed the medication log(s) for Resident A. The medication log
for 04/22/2013 did not indicate that Ms. Hunter had given Resident A Carnation
Instant Breakfast as instructed if Resident A refuses a meal.
On 04/13/2013, I conducted by telephone an exit conference with the licensee
designee, Chad Underlay.
Mr. Underlay acknowledged that if the Carnation Instant Breakfast was not
documented as passed on the medication log, it must be treated as not having been
passed.
APPLICABLE RULE
R 400.14310 Resident health care.
(1) A licensee, with a resident's cooperation, shall follow the
instructions and recommendations of a resident's physician or
other health care professional with regard to such items as any
of the following:
(d) Other resident health care needs that can be provided in
the home. The refusal to follow the instructions and
recommendations shall be recorded in the resident's record.
ANALYSIS:
CONCLUSION:
Staff person Ruth Hunter failed to give Resident A Carnation
Instant Breakfast as prescribed and listed on Resident A’
medication log(s) as it was not documented as having been
passed.
VIOLATION ESTABLISHED
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IV.
RECOMMENDATION
Upon receipt of an acceptable plan of correction, I recommend that the status of the
license remain unchanged.
05/17/2013
________________________________________
Grant Sutton
Date
Licensing Consultant
Approved By:
05/17/2013
________________________________________
Jerry Hendrick
Date
Area Manager
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