Rule/Regulation Violated:
B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and:
1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services:
a. Includes whether the individual requires:
i. Continuous medical services,
ii. Continuous or intermittent nursing services, or
iii. Restraints; and
b. Is dated and signed by a:
i. Physician,
ii. Registered nurse practitioner,
iii. Registered nurse, or
iv. Physician assistant; and
Evidence/Findings:
Based on record review and interview, the manager failed to ensure before or at the time of acceptance the individual submitted documentation dated within 90 calendar days before the individual was accepted by the facility, to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant, for three of three residents. The deficient practice posed a risk if the facility was unable to meet a resident's needs and the Department was unable to determine substantial compliance as the required documentation was not in the medical records at the time of the inspection.
Findings include:
1. A review of R2's medical record revealed no evidence of a "Pre-Admission Determination," or any documentation dated within 90 calendar days before the individual was accepted by the assisted living facility and included whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, and was dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant.
2. In an interview, E3 acknowledged there was no evidence of "Pre-Admission Determination" documentation and no documentation whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints, dated and signed by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.
Summary:
The following deficiencies were found during the on-site compliance inspection and investigation of complaint AZ00189503 conducted on August 14, 2024: