MINNIE LEE'S SENIOR HOME CARE

Based on record review and interview, the manager failed to ensure a resident's medical record contained documentation of freedom from infectious tuberculosis (TB), for one of two residents sampled. The deficient practice posed a TB exposure risk to residents, and the Department was unable to determine substantial compliance during the inspection. Findings include: R9-10-113(B) A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC), ii. Was administered within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution, and iii. Includes the date and the type of tuberculosis screening test; b. If the individual had a history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, compliance with subsection (A)(2)(b); or c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R9-6-101; and ii. Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution; 1. A review of R2's (admitted in 2023) medical record revealed documentation of freedom from infectious TB was not available for review. 2. In an interview, E1 acknowledged R2's medical record did not contain documentation of freedom from infectious TB. E1 reported R2 had documentation of freedom from infectious TB, however, E1 was unable to locate the requested documentation.

Based on record review and interview, the manager failed to ensure a resident's medical record contained the resident's service plan and updates, for one of two residents sampled. The deficient practice posed a risk as a service plan directs the services to be provided to a resident, and the Department was unable to determine substantial compliance during the inspection. Findings include: 1. A review of R2's (accepted in 2023) medical record revealed documentation of a written service plan was not available for review. Based on R2's date of acceptance, a service plan was required. 2. In an interview, E1 acknowledged R2's medical record did not contain a written service plan. E1 reported a service plan for R2 was completed, however, E1 was unable to locate the requested documentation.