Inspection Details
Inspection #
INSP-0115529
Inspection Date(s)
4/1/2025
Status
Complete
Inspection Type
Complaint
Worksheet Type
Assisted Living Center
Certificate Number
AL11240C
Location Type
—
Initial Comments
The following deficiencies were found during the on-site compliance inspection and investigation of complaints 00105710 and 00105171 conducted on April 1, 2025:
Statement of Deficiency
2 deficiencies found
Deficiency #1
R9-10-803
✓ Plan Provided
▼
Rule
R9-10-803.A.9. Administration
A. A governing authority shall:
9. Ensure compliance with A.R.S. § 36-411.
Evidence
Plan of Correction
Responsible Person
Taylor Jackson, Facility Manager
Temporary Correction Date
2025-05-15
Permanent Correction Date
2025-05-15
Temporary Solution
Our temporary solution for this plan of correction was to perform a proper previous employment check for the caregivers listed and notate it on their applications. Which are attached. We are also completing an audit on current employees to perform any additional employment checks that were missing or that were not performed correctly.
Permanent Solution
In order to better complete the task of employment verification I have updated our application to include the code stating the need for employment verification and I have added a section after each work history for that verification to be performed and written. See attached application. This is the application we will use going forward for all future staff and it must be completed prior to starting employment. There is also a notice to future employees that any gaps of employment larger than 6 months will require more information and possibly a new application for fingerprint clearance card.
Monitoring
We will be performing quarterly employee binder audits to ensure that these verifications are complete along with verifying that all other required documentations are up to date and in their binder.
Deficiency #2
R9-10-816
✓ Plan Provided
▼
Rule
R9-10-816.B.3.b. Medication Services
B. If an assisted living facility provides medication administration, a manager shall ensure that:
3. A medication administered to a resident:
b. Is administered in compliance with a medication order, and
Evidence
Plan of Correction
Responsible Person
Taylor Jackson, Facility Manager
Temporary Correction Date
2025-04-29
Permanent Correction Date
2025-05-15
Temporary Solution
In response to this deficiency, we performed a medication reconciliation for the resident listed in the deficiency to ensure that our medication list is now accurate and current and had him sign it. Which I will attach for your review.
Permanent Solution
I updated our entire medication policies and added a medication order audit section to better address verifying orders and communicating with the physician more frequently to verify our orders are correct. As well as I included the language of R9-10-816.B.3.b. under our medication administration section. We then had our nurse review and sign off on our policies, which are now implemented
Monitoring
Two times a month I will be having a medication administration meeting with my management team to go over the audits, successes and challenges we are having with all medication management processes and make any needed changes or updates to our policies and procedures to ensure that we are staying up to date on our medication order compliance.