SPRINGVALE — The owner of Oak Street Residential Care Facility has appealed a decision by the Department of Health and Human Services to revoke its conditional operating license. A hearing is scheduled for Dec. 12.

The 10-bed elder care facility has been operating on a conditional license since February.

In documents addressed to owner Maureen Casey dated Aug. 22, Phyllis Powell, the assistant director of the medical facilities unit of the Division of Licensing and Regulatory Services, outlined two dozen deficiencies found in follow-up inspections in April, June and August, and said the facility had failed to comply with several license conditions.

“In addition, the facility failed to pass an inspection by the State Fire Marshal’s Office,” Powell wrote. “Specifically, the State Fire Marshal’s Office found serious violations of life safety codes.”

Oak Street Residential Care Facility was initially placed on conditional licensure status Feb. 26 after a state inspection turned up violations ranging from missed medication to forbidding one resident to shower more than once a week. In one instance outlined in the initial report, personal funds of a resident were deposited with business funds of the facility. The report noted money and other items reported missing from residents’ rooms was not reported to DHHS.

The documents obtained this week from DHHS by the Journal Tribune through a Freedom of Access Act request, refer to an alleged failure by the facility to ensure adequate maintenance, timed fire drills with full evacuation of the facility during drills and appropriately trained staff for evacuations. The facility had inadequate staff to meet the needs of residents on the afternoon and evening shifts on two occasions in June and again in August. The letter outlines incomplete policies, documentation and follow-through on submitted plans for correcting the deficiencies. The facility had on July 31 submitted a plan to have two staffers on duty at all times; an unannounced inspection Aug. 3 found only one staffer on duty, according to the documents provided by the state.

There was one staff person on duty to evacuate eight residents at 6 a.m. June 15 when an unannounced fire evacuation drill by the local fire marshal took place, according to the documents. The staffer explained an evacuation couldn’t take place because two residents needed two staff workers to help them out of bed and to walk.

A second fire drill with three staff members at 8 a.m. that day took more than 12 minutes because a resident became immobile on the stairway.

Interviews with staff Aug. 3 and 7 indicate there had been no training on evacuations since the June 15 fire drill.

According to the documents, when staff were asked by inspectors how evacuation times could be improved, one staffer said, “I don’t know, I guess they (residents) will just have to walk faster.”

The documents allege a staff member told a state inspector he or she had been told not to talk to them and expressed concern about job security.

The documents show some fire drills were conducted by phone or in person by the administrator and residents would gather in the dining room to talk about what they would do to evacuate, although fire drill logs indicated evacuations always occurred. The logs also noted some residents chose not to participate, while others were unable to do so.

The letter references a lack of documentation concerning some residents’ medications including the whereabouts of leftover medication that had been discontinued, and the unavailability of some medications like Milk of Magnesia, calcium tablets and hydrocortisone cream.

The documents state that an individual whose certification to administer medications expired May 5 continued to dispense medications until June 20.

The documents refer to inadequate record keeping and referenced one case where a resident’s record failed to include the name, full address and telephone number of the individuals to be contacted in an emergency.

A policy outlined disciplinary consequences for medication errors, but reports show one worker made four errors in one week and eight errors another week. The staffer was scheduled to work 48 hours one week and 55 hours another week.

Two plans of correction were submitted by Oak Street Residential Care Facility; one appears to address the initial deficiencies noted in February. The plan included hiring of an additional administrator in May to provide training and revise and create policies to support residents’ rights. Training with a registered nurse consultant was scheduled in June, the resident move-in process was revised, a weekly house inspection was planned to be implemented, along with a maintenance log.

A second plan of correction refers to the recognition by the owner that additional staff was needed to meet safety requirements. It noted a staff member had received additional training on medication distribution. The plan states the facility would reorder needed medications when the resident’s family was unable to provide them in a timely manner. It noted the staff person whose license to administer medication was expired was removed once the discovery was made and that person was enrolled in a 40-hour class for recertification. The plan outlined new procedures for medication lock boxes, and said on-call maintenance staff had been hired and that outstanding maintenance issues had been resolved.

The plan indicates an agency had provided staffing for second and third shifts while the facility continued to seek permanent employees.

Evacuation plans were to be re-written and silent fire drills discontinued. The plan submitted by Oak Street Residential Care Facility calls for the facility to contact the local fire marshal for education training for both staff and residents.

Neither Casey, the owner, nor administrator Deborah Dryden were available for comment Thursday. The person who answered the phone at the facility said Casey was expected to return Sunday and Dryden on Monday. A telephone message left for Geismar, the attorney, was not returned.

In a Sept. 7 letter to the Division of Licensing and Regulatory services requesting a hearing, Geismar said his client believes the licensing action taken by the department is incorrect and that the owner is “aggrieved by the decision.”

“Our staff continues to remain actively involved at the facility to ensure that the residents are safe and that no resident is placed in immediate jeopardy,” said DHHS Spokesman John Martins, last week.

— Senior Staff Writer Tammy Wells can be contacted at 324-4444 (local call in Sanford) or 282-1535, Ext. 327 or [email protected].