Investigation leads to changes at The Terrace

The Terrace, an assisted living facility run by Homer Senior Citizens, has made numerous changes to its operation and management following an investigation and report by state health officials, Homer Senior Citizens executive director Keren Kelley said this week.
“We did some things wrong. We’ve improved. We’re human,” she said in response to the investigation.
“My staff has worked above and beyond those issues that were presented … We went further than the report did.”
Health officials in January inspected The Terrace and found that it had made changes stipulated in a plan of correction required after the Alaska Department of Health and Social Services, Division of Health Care Services, Certification and Licensing, issued a report of investigation and notice of violation last fall.
“They made significant corrections,” said Michelle Ziemer, certification and licensing program manager, and one of the officials who investigated The Terrace.
“We found everything to be meeting licensing standards.”
The report of investigation and notice of violation resulted in a $10,000 fine against The Terrace, reduction of the facility’s biennial license to a provisional license and a requirement that The Terrace submit a plan of correction by Sept. 20, 2012. It did so, Ziemer said.
Homer Senior Citizens could have requested a hearing, but did not do so, Ziemer said.
While the Homer News received the report on The Terrace from a source who asked to remain anonymous, Ziemer said the report is publicly available through her office. The plan of correction is not a public document.
Kelley said a lot of the issues were being addressed before the investigative report came out and that her staff has worked hard to fix the issues raised.
“They’re awesome. I have the best staff in this community,” Kelley said.
Ziemer said the $10,000 fine could be applied to any money spent by Homer Senior Citizens to address issues, and no money would actually go to the state. Kelley said Homer Senior Citizens spent $58,000 in making improvements addressed by the investigation, including hiring more staff.
According to the report, the Division of Health Care Services received five complaints or reports of incidents in a period from May 17 to Aug. 9, 2012. Kelley has been director since August 2011.
The state investigated those complaints last May and in August. The report was based on site visits and inspections, staff and resident interviews, document reviews and interviews with doctors, health care providers and family members.
The allegations made were that The Terrace:
* May have failed to meet the medical needs of the residents;
* May not have followed prescribed dietary guidelines;
* May have failed to provide medications correctly;
* May not have documented as-needed use of prescription drugs, including controlled substances;
* May not have provided adequate staffing; and
* May have practiced outside the scope of its license.
And that:
* The administrator may not have provided proper oversight;
* Staff may not have been adequately trained; and
* A staff person may have sexually assaulted a resident.
Ziemer said in investigating allegations, it applies a “more likely than not” standard.
“We’re dealing with vulnerable individuals,” she said. “We’ll substantiate and act on that. Our job is to insure the safety of residents.”
The report said staffing levels were low, with two resident assistants for 27 residents at a time during one morning visit last July. It also said staff may not be getting good training, such as how to transfer patients. Kelley said she has hired more staff and is giving them more training, and even making training available to family and the public. The Terrace now has one registered nurse and two licensed practical nurses, Kelley said, and has three certified nursing assistants or resident assistants on duty per day. New employees have two weeks of on-the-job training before working alone with residents.
Some of the complaints alleged that nurses or residential assistants did not take careful notes regarding dietary or medical procedures. For example, one family member of a female resident said the woman was dehydrated. Daily nursing progress notes showing that the woman drank fluids were either unsigned or missing, the report said. In that case, the woman was taken to South Peninsula Hospital for severe dehydration and moved to Long Term Care.
The nurse who made but did not sign those notes also was alleged to have not received proper oversight from Kelley. Kelley said that nurse no longer works at The Terrace.
In another case, the report alleged a resident with choking issues was given French toast soaked in milk and prunes and not given his prescribed diet of pureed food. On one visit, a home health nurse noticed the man choking and he eventually coughed up a whole prune.
The report said that staff did not document blood-sugar levels that would indicate the amount of insulin needed and that adequate oversight wasn’t being done to assist residents with medications.
In another incident, a resident receiving Oxycodone, a prescribed controlled substance for pain, could take pills as needed. The report said some records documenting the pill count were inaccurate.
The report also said staff had failed to follow hospital discharge orders for a man who returned to The Terrace after being treated at South Peninsula Hospital for high Coumadin levels. The man was not to get Coumadin, a blood-thinning medication, but a nurse failed to notify The Terrace pharmacy of the discharge orders and he received Coumadin. The man later started coughing up blood and went back to the hospital.
In response to that event, the nurse and Kelley signed an incident report. As a follow up, Kelley documented a procedure that only one person per shift was to give medications, that the registered nurse was to review the daily medication log and the home was to order a medication cart.
Kelley said that in response to the issue of administering medications, The Terrace now has a three-point checklist.
“We have a true checks-and-balances in place,” she said. “That is something I as an administrator put in.”
Regarding the alleged sexual assault, Kelley said she reported the incident to Adult Protective Services.
Ziemer said she did not know if any actions were taken. Such investigations are confidential, she said. The Homer Police did not investigate that allegation. A search of online court records shows no charges filed.
The report said the resident assistant involved had a short temper, showed disrespect for personal boundaries and likely failed to treat the resident with respect for his personal dignity. That employee no longer works at The Terrace, Kelley said.
Kelley said the next inspection of The Terrace is in August. Ziemer said that based on that investigation The Terrace could then go back to being issued an every-two-year license.
Michael Armstrong can be reached at