Correction: An earlier version of this story misidentified the individual who said the incident did not constitute possible neglect. It was the facility administrator who Health Department investigators said told the director of nursing not to report the incident.A Broken Arrow facility that provides housing and employment services to adults with intellectual disabilities is facing possible termination from the Medicare and Medicaid program after an Oklahoma Department of Health investigation found evidence of neglect and “immediate jeopardy” to residents.
The Gatesway Foundation, a nonprofit organization that has helped adults with intellectual disabilities with housing and employment for more than 50 years, could also face sanctions from the state for the alleged violations found at one of its facilities during the May 29 investigation, which found evidence of neglect, according to the Oklahoma Health Department.
The Health Department investigation was conducted after a complaint alleging that one of Gatesway’s intermediate care facility residents, who has an intellectual disability and requires assistance bathing, had soiled herself in a dining area but was left in her room without being cleaned by the sole staff member present at the time. The complaint also alleged another client was ordered by the staff member to clean up the mess that had been left by the other client, the Health Department report states.
The Health Department found the complaint to be true, and that Gatesway had failed to investigate and report an instance of abuse or neglect.
Gatesway has submitted a plan to the Health Department to correct the deficiencies found by the investigation, and that plan has been accepted by the Health Department, according to a spokesman for the agency. Part of the plan states Gatesway will provide training on abuse and neglect to staff, as well ensuring adequate staffing at its facilities.
The organization has until Aug. 13 to prove the deficiencies have been corrected during a revisit by inspectors. Failure to do so would mean the facility would have its Medicaid provider agreement terminated, according to the Health Department.
In a statement, Gatesway’s Interim President Gloria Morton said after the survey was conducted, staff members were immediately assembled for refresher training on the areas relative to the survey’s findings and the immediate jeopardy finding was removed by midnight that night.
“On the date in question, an employee from the surveyed cottage briefly went to dispense medications in another cottage to cover an absent employee, according to the ICF (intermediate care facility) administrator,” Morton said. “The ICF division is fully staffed, with five new employees going through training and five more in the pipeline. We are actively recruiting and training qualified candidates.”
A separate Health Department investigation conducted on May 14, also spurred by a complaint, found that the organization had attempted to remove at least two clients from its services without sufficient cause, according to Oklahoma State Department of Health documents.
An investigation by The Frontier in late May found that for the past year, Gatesway has been in dire straits financially, cutting staff and removing clients who were determined to be “unprofitable.”
According to internal documents obtained by The Frontier, one of the organization’s board members who had been formulating ways for the organization to regain its footing had requested that certain clients have a profit margin of at least 20 percent to remain Gatesway clients.
In addition, to try and shore up its financial position Gatesway has also put almost all of its properties up for sale, sold off much of its vehicle fleet and lawn service equipment, cut wages and laid off workers.
Though the organization had in the past blamed funding cuts from the state and increased health care costs for some of its more visible cutbacks, internal documents obtained by The Frontier showed that mismanagement by Gatesway officials also played a role in the organization’s situation.
Records showed former Gatesway CEO Jim Pacula had given pay raises to many of the organization’s workforce during the funding cuts, hired family members to work for the organization and used the organization’s funds to purchase steak dinners and lease a car, while the organization spent tens of thousands of dollars on consultants closely connected to Gatesway board member and former Deloitte executive Greg Arend. Arend, the documents showed, headed the effort to regain the organization’s financial footing after Pacula was pushed out as CEO in late May 2017.
Recently, Gatesway has been able to make significant strides in shoring up its financial situation, though it still needs donors to help sustain its mission, board member John Feary told The Frontier.
A few weeks after The Frontier’s story about Gatesway’s financial position, the organization began distributing confidentiality agreements required to be signed by employees and placed in their file, according to documents obtained by the Frontier.
However, Morton said the confidentiality agreements have been a requirement for employees in the past, and that the distribution of the agreements to employees is part of the organization’s larger restructuring efforts.
“Because we’re undergoing so many changes, we’re reviewing our policies to ensure they unite and guide us on our common mission,” Morton said. “The (confidentiality) policy we redistributed on June 29 is the same policy we’ve always required. Rather than go through every employee’s file to ensure they’ve signed every policy under review, we’re starting with a clean slate, and obtaining new signed policies on several important topics.”
In a June 8, 2018, letter to Gatesway administrators, the Oklahoma State Department of Health outlined violations of Medicaid guidelines for patients that constituted “immediate jeopardy” regarding client protections, staff treatment of clients and to clients and other
Health Department inspectors conducted an unannounced visit on the morning of May 29 after a complaint was made to the department alleging that the facility was not providing care and services according to client needs. That allegation, inspectors reported, was substantiated.
The findings of the inspection state that the organization failed to report, investigate and protect clients from an incident of neglect, in violation of state, federal and its own policies.
Eight clients reside at that Gatesway facility, which is a cottage on the main Broken Arrow campus, the report states.
According to the investigation, a client who had a mild intellectual disability,and suffered frequent bowel and bladder incontinence, required assistance when bathing and had limited mobility to a degree where she needed the aid of a walker or wheelchair to get around. The resident had just moved into the facility earlier that month, the report said.
Investigators viewed video recorded on May 7 from a surveillance camera that included video from the facility’s dining area and the hallway leading to residents’ rooms, the report states.
Using the video, and through interviews with staff and clients, Health Department investigators concluded that a qualified intellectual disabilities professional (QIDP) and a certified medication aid were the only two staff members at the facility on the evening of May 7, but that the certified medication aid had left the facility just before 6 p.m. to administer medications at a sister facility on the Gatesway campus.
At the time, most of the residents were in the facility’s dining area and the lone staff member in the facility was in an office area, the report states.
Around 6 p.m., another resident saw where the newly-arrived resident had soiled herself and left feces on the floor, the report states. That resident summoned the lone staff member, who came to the dining area.
The report states that the staff member then helped the resident to her walker and, seeing feces running down her leg, told her to take a shower. The staff member also told the resident who had reported the issue to clean the mess up before back to the office area, the report states.
The newly-arrived resident could be seen using her walker to go to her bedroom, and though the staff member told investigators she had helped the resident shower, surveillance video showed that no staff members had assisted the resident in her cleaning herself, the report states.
The resident who was asked to clean the feces left on the floor of the dining area could be observed putting on disposable gloves, putting a paper towel over the feces, and then backed away after bending over to pick it up, the report states.
The feces remained on the floor for around 27 minutes before the staff member returned and assisted a resident in cleaning it up, though the area was not disinfected, the report states.
The facility’s director of nursing said she knew of incidents where the client had been left soiled and unattended but told investigators that when she asked the facility administrator whether the incident should be reported and investigated as possible neglect, she was told “no,” the report states. However, an assistant administrator who viewed the surveillance video of the incident also questioned whether it should be reported and investigated but was also told by the facility administrator that it would not be investigated further, the Health Department report states.
When questioned by Health Department investigators, the staff member said two direct care staff members were required to be present at all times, and that there had not been sufficient staff there to assist the resident in cleaning herself, the report states. Surveillance video shows that the staff member was the only one present at the facility for nearly two hours.
When asked by Health Department investigators if there had been enough staff members at the facility to provide care to the resident after the toileting accident, the facility administrator said there had not been, the report states. When asked by investigators whether the staff member’s failure to provide assistance to the client could be considered neglect, the administrator did not answer, according to the report.
The investigators stated that failure to report the incident to the Department of Health and an apparent lack of investigation of the incident by the facility were also violations of the requirements.
The staff member was given a formal reprimand and put on 90-day probation, and the organization quickly implemented a plan of removal of the immediate jeopardy situation by providing staff additional training, offering to revise its policies and ensuring enough staff are present at each of the cottages on campus to provide care to residents, the report states.
Gatesway submitted a plan of correction to the Health Department on June 11, and the plan was found to be acceptable by the department on June 20. However, a revisit to ensure the plan is in place and the deficiencies have been corrected is required before Aug. 13, according to the Health Department.
Another inspection by the Health Department on May 14 found that two Gatesway clients were discharged from receiving services without a good cause.
The Health Department report states that both clients were issued 30-day involuntary discharge notices in early April that stated the clients had met the highest level of active treatment available at Gatesway, and that the organization would not be able to provide any treatment beyond this. Clients, guardians and staff are required to meet and come up with treatment goals for the clients annually to measure their progress.
However, after a complaint was made about the discharges, Health Department investigators found that, during the four previous months, only a handful of days’ worth of documentation regarding the client’s progress toward their treatment goals and objectives had been logged, and no up-to-date quarterly review had been yet conducted over the clients’ individual habilitation plans, the report states.
The facility administrator, assistant administrator and another staff member interviewed by the department said not enough time had elapsed to conduct a quarterly review of the progress toward goals in the clients’ plans, and that the progress toward the goals had not been thoroughly documented, the report states.
Asked by Health Department investigators whether the clients should have been discharged, given the lack of documentation, the staff members “all stated, ‘No,’” according to the report.
In a statement to The Frontier, Gatesway interim President Gloria Morton said the attempt to discharge the clients who were the focus of the Health Department report was not in accordance with the organization’s policies, and a plan of corrective action was submitted to the Health Department.
“Gatesway determined the discharge of the clients failed to meet our high standards. Our staff members work diligently to develop and implement an Individualized Habilitation Plan (IHP) for each resident, and document the resident’s progress through each milestone,” Morton said. “If our interdisciplinary team determines, in concert with the client’s guardian, that the client is not thriving at Gatesway, we find a more suitable placement where the client has a greater likelihood of success. Our policy is to give the client and guardian 30 days to transition to the new program. That standard was not met in this case, and we’ve taken the appropriate actions to ensure our clients and their families can count on us to do what our policies say we do.”
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