Inspection Details

Inspection #
INSP-0075583
Inspection Date(s)
8/30/2023
Status
Complete
Inspection Type
Complaint
Worksheet Type
Assisted Living Center
Certificate Number
AL8636C
Location Type
โ€”

Initial Comments

An on-site investigation of complaint AZ00198558 was conducted on August 30, 2023, and the following deficiencies were cited.

Statement of Deficiency

2 deficiencies found
Deficiency #1
✓ Plan Provided
Rule
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 3. Includes the following: b. The level of service the resident is expected to receive;
Evidence
Based on record review and interview, for one resident reviewed, the manager failed to ensure a resident had a written service plan to include the level of service the resident was expected to receive. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: A.R.S. \'a7 36-401.38 defines "Supervisory care services" to mean general supervision, including daily awareness of resident functioning and continuing needs, the ability to intervene in a crisis and assistance in the self-administration of prescribed medications. A.R.S. \'a7 36-401.38 defines " Personal care services" to mean assistance with activities of daily living that can be performed by persons without professional skills or professional training and includes the coordination or provision of intermittent nursing services and the administration of medications and treatments by a nurse who is licensed pursuant to title 32, chapter 15 or as otherwise provided by law. A.R.S. \'a7 36-401.38 defines "Directed care services" means programs and services, including supervisory and personal care services, that are provided to persons who are incapable of recognizing danger, summoning assistance, expressing need or making basic care decisions. 1. In record review, R1's medical record included a service plan dated March 24, 2023; however, did not include documentation of the level of service the resident was expected to receive. 2. During an interview, E1 acknowledged R1's service plan did not include the level of service R1 was expected to receive, and that R1 received personal care services.
Plan of Correction
Permanent Correction Date
2023-09-05
Deficiency #2
✓ Plan Provided
Rule
A. Except as required in subsection (B), a manager shall ensure that a resident has a written service plan that: 4. Is reviewed and updated based on changes in the requirements in subsections (A)(3)(a) through (f): a. No later than 14 calendar days after a significant change in the resident's physical, cognitive, or functional condition; and
Evidence
Based on record review, and interview, for one resident reviewed, the manager failed to ensure a resident had a written service plan that was reviewed and updated after a significant change in the resident's condition. The deficient practice posed a risk to a resident if the service plan did not include a description of the resident's condition, for which services were to be provided. Findings include: "Service plan" means a written description of a resident's need for supervisory care services, personal care services, directed care services, ancillary services, or behavioral health services and the specific assisted living services to be provided to the resident. 1. In record review, R1's medical record (received personal care services) included documentation R1 was not feeling well, was hospitalized for a few days, and returned to the facility with Hospice services initiated. R1's record included a service plan, dated March 24, 2023. Based on R1's change of condition, an updated service plan was required. 2. During an interview, E1 reported R1 wasn't feeling well, was sent to the hospital and diagnosed with a "mass." R1 returned to the facility and Hospice services were initiated. E1 reported R1's service plan was not reviewed and updated, and acknowledged a service plan was required no later than 14 days after a resident's change in condition.
Plan of Correction
Permanent Correction Date
2023-09-05