Inspection Details

Inspection #
INSP-0061334
Inspection Date(s)
8/25/2023
Status
Complete
Inspection Type
Complaint;Compliance (Annual)
Worksheet Type
Assisted Living Center
Certificate Number
AL11558C
Location Type
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Initial Comments

The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00189288 conducted on August 25, 2023:

Statement of Deficiency

3 deficiencies found
Deficiency #1
✓ Plan Provided
Rule
36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.
Evidence
Based on record review and interview, the health care institution failed to administer a training program regarding fall prevention and fall recovery, for five of five personnel members sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. A review of E1's, E2's, E3's, E4's, and E5's personnel records revealed documentation of fall prevention and fall recovery training was not available for review. 2. In an interview, E1 reported E1, E2, E3, and E4 completed fall prevention and recovery training at least once during the past year. However, the documentation was made available for review within the time frame required by the Department. E1 acknowledged there was no documentation of completed training in fall prevention and recovery by E5 because E5 was a temporary caregiver. E1 did not know if E5 completed the training through the temporary agency.
Plan of Correction
Permanent Correction Date
2023-10-19
Deficiency #2
✓ Plan Provided
Rule
C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: b. Cover orientation and in-service education for employees and volunteers;
Evidence
Based on record review, documentation review, and interview, the manager failed to ensure policies and procedures were implemented to protect the health and safety of a resident covering orientation for employees, for one of five personnel members sampled. The deficient practice posed a risk as the established and documented policies and procedures were not followed. Findings include: 1. A review of E5's personnel record revealed documentation of completed orientation was not available for review. 2. A documentation review revealed a policy and procedure titled "Staff Orientation and In-Service Training" (updated May 2023). The policy indicated all staff would receive orientation specific to their job duties at the time of hire. This orientation was to be documented and retained in the personnel members' personnel records. 3. A documentation review revealed a job description for a caregiver indicated caregivers were to "complete full orientation upon hire." 4. In an interview, E1 acknowledged E5 did not complete orientation according to policies and procedures at the time of E5's date of hire. E1 reported E5 was a temporary caregiver from a temporary employment agency. E1 reported providing E5 with a brief orientation; however, E1 acknowledged E5 did not complete orientation according to the facility's policies and procedures. E1 was not aware this was necessary due the temporary status of employment.
Plan of Correction
Permanent Correction Date
2023-10-19
Deficiency #3
✓ Plan Provided
Rule
C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual's name, date of birth, and contact telephone number;
Evidence
Based on record review and interview, the manager failed to ensure a personnel record for each employee included the individual's contact telephone number, for one of five personnel members sampled. Findings include: 1. A review of E5's personnel record revealed a telephone number was not available for review. 2. In an interview, E1 reported E5 was a temporary caregiver. E1 did not have E5's telephone number because the temporary employment agency did not share this information. E1 reported to utilize the temporary agency when E1 needed to contact E5.
Plan of Correction
Permanent Correction Date
2023-10-19