Inspection Details

Inspection #
INSP-0071001
Inspection Date(s)
9/18/2023
Status
Complete
Inspection Type
Compliance (Annual)
Worksheet Type
Assisted Living Home
Certificate Number
AL9128H
Location Type
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Initial Comments

The following deficiencies were found during the on-site compliance inspection conducted on September 18, 2023:

Statement of Deficiency

2 deficiencies found
Deficiency #1
R9-10-113 ✓ Plan Provided
Rule
R9-10-113. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution;
Evidence
Based on documentation review, record review, and interview, the health care institution failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB to individuals employed by the health care institution. The deficient practice posed a risk as the caregiver received no organized instruction or information related to TB surveillance. Findings include: 1. Review of facility's documents revealed a policy titled "Tuberculosis (TB) Control - Tuberculosis Screening" that stated "...All individuals employed by the facility or providing volunteer services for the facility will be required to complete Tuberculosis (TB) Training and Education upon hire and annually thereafter..." 2. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of August 11, 2023. The personnel record did not include documentation of training and education related to recognizing the signs and symptoms of TB. 3. In an interview, E1 and E2 acknowledged documentation was not available showing E3 completed training and education related to recognizing the signs and symptoms of TB. 4. Technical assistance was provided on this Rule during the compliance inspection conducted September 12, 2022.
Plan of Correction
Permanent Correction Date
2023-09-19
Deficiency #2
R9-10-113 ✓ Plan Provided
Rule
R9-10-113. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis;
Evidence
Based on documentation review and interview, the health care institution failed to implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. Review of facility's documents revealed a policy titled "Tuberculosis (TB) Control - Tuberculosis Screening" that stated "...The facility will be assessed on an annual basis to determine TB risk. This assessment will be completed on the facility form called "Facility Tuberculosis Risk Assessment" at least once every 12 months..." 2. Review of facility documentation revealed no documentation of an annual assessment of the health care institution's risk of exposure to infectious TB. 3. In an interview, E1 and E2 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted. 4. Technical assistance was provided on this Rule during the compliance inspection conducted September 12, 2022.
Plan of Correction
Permanent Correction Date
2023-09-20