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Residential Care Services Investigation Summary Report
Provider/Facility: Harmony Haven Adult Family HomeLLC (801055)
Intake ID(s): 3281102
License/Cert. #: AF752541Investigator: Witman, Jennifer Region/Unit: RCS Region 2/Unit B Investigation
Date(s):10/31/201612/30/2016
through
Complainant Contact Date(s): 10/21/2016Allegations:1. The named resident was being neglected.
2. The environment in the adult family home (AFH) was dirty and unsafe.
Investigation Methods:Sample: 6 residents. Observations: Environment, staff/staff
interactions,staff/residentinteractions,resident/residentinteractions and careprovision.
Interviews: Staff, residents andothers not associatedwith the facility.
Record Reviews: Incident reports, residentrecords and facilityrecords.
Allegation Summary:1. The named resident developed a bedsore in July and had wound care by home health and then transitioned to Hospice. TheAFH was not properly staffing the AFH and not providing the care and services needed to prevent skin breakdown. See theStatement of Deficiency dated 09/23/16. On 10/24/16 an unqualified caregiver gave the named resident a potentially lethaloverdose of The named resident required hospitalization for 2 days. The provider allowed the caregiver to give allmedications to all residents. The caregiver failed to have registered nurse delegation to give the medications to the namedresident. After the overdose occurred the provider continued to allow the caregiver give medications to the named residentwithout nurse delegation. Failed practice was found.
1. Observation of the AFH revealed a muddy floor covered with dog hair. The AFH was also found to have a cluttered kitchen anddining area. Failed practice was found.
Page 1 of 2
Residential Care Services Investigation Summary Report
Unalleged Violation(s):None.
Yes No
Conclusion /Action:
Failed Provider Practice Identified /Citation(s) Written
Failed Provider Practice Not Identified /No Citation Written
WAC 388-76-10020 (1), WAC 388-76-10430 (1, 2d), WAC 388-76-10455 (2), WAC 388-76-10670 (2, 4), WAC 388-76-10750-1.
Page 2 of 2
Residential Care Services Investigation Summary Report
Provider/Facility: Harmony Haven Adult Family HomeLLC (801055)
Intake ID(s): 3281950
License/Cert. #: AF752541Investigator: Witman, Jennifer Region/Unit: RCS Region 2/Unit B Investigation
Date(s):10/31/201612/30/2016
through
Complainant Contact Date(s): 11/01/2016Allegations:The named resident received an overdose of (a potent long acting narcotic pain medication).
Investigation Methods:Sample: 6 residents. Observations: Environment, staff/staff
interactions,staff/residentinteractions,resident/residentinteractions and careprovision.
Interviews: Staff, residents andothers not associatedwith the facility.
Record Reviews: Incident reports, residentrecords and facilityrecords.
Allegation Summary:The named resident was on Hospice. The named resident was prescribed several as needed medications for pain and scheduledmedications for pain. The medications were in liquid form The named resident required the caregivers to be nurse delegated toadminister the medications to the resident due to and Three caregivers were giving medications to thenamed resident without the required nurse delegation. One of the caregivers mistakenly gave the named resident a lethal sizedoverdose of The named resident required 2 days of hospitalization for the treatment of the overdose. The providerof the AFH allowed the 3 caregivers to continue to give medications without nurse delegation after the medication erroroccurred. Failed practice found.
Unalleged Violation(s):None.
Yes No
Page 1 of 2
Residential Care Services Investigation Summary Report
Conclusion /Action:
Failed Provider Practice Identified /Citation(s) Written
Failed Provider Practice Not Identified /No Citation Written
WAC 388-76-10020 (1), WAC 388-76-10430 (1, 2d), WAC 388-76-10455 (2), WAC 388-76-10670 (2, 4), WAC 388-76-10750-1.
Page 2 of 2
Completion DateLicense #: 752541
January 16, 2017
1Page 9of
Harmony Haven Adult Family Home LLCPlan of Correction
STATE OF WASHINGTONDEPARTMENT OF SOCIAL AND HEALTH SERVICES
AGING AND LONG-TERM SUPPORT ADMINISTRATION3906-172nd St NE, Suite #100, Arlington, WA 98223
Statement of Deficiencies
Licensee: Harmony Haven LLC
Jennifer Witman, RN, BSN, Complaint Investigator
From:
DSHS, Aging and Long-Term Support Administration
Residential Care Services, Region 2, Unit B
3906-172nd St NE, Suite #100
Arlington, WA 98223
(360)651-6872
You are required to be in compliance with all of the licensing laws and regulations at all times to
maintain your adult family home license.
The department has completed data collection for the unannounced on-site complaint
investigation of: 10/31/2016, 12/2/2016 and 12/30/2016
Harmony Haven Adult Family Home LLC
1231 Warner St
Sedro Woolley, WA 98284
As a result of the on-site complaint investigation the department found that you are not in
compliance with the licensing laws and regulations as stated in the cited deficiencies in the
enclosed report.
I understand that to maintain an adult family home license I must be in compliance with all the
licensing laws and regulations at all times.
This document references the following complaint numbers: 3281102 , 3281950
The department staff that inspected and investigated the adult family home:
DateResidential Care Services
DateProvider (or Representative)
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