ARDEN VALLEY HOME CARE

Based on record review and interview, the manager failed to ensure a caregiver or an assistant caregiver documented the services provided to a resident in the resident's medical record, for two of two sampled residents.

Findings include:

1. A review of the medical records of R1 and R2 revealed current service plans which indicated R1 and R2 were to receive assistance with dressing. The review further revealed documentation of assisted living services provided to R1 and R2 (ADLs) dated July 2024 and August 2024. However, the ADLs revealed no documentation demonstrating a caregiver or assistant caregiver assisted R1 and R2 with dressing during those months and no place designated on the ADLs to document assistance with dressing.

2. In an interview, E2 reported the ADLs did not contain a place to document assistance with dressing. E2 reported caregivers assisted R1 and R2 with dressing but did not document it.

This is a repeat citation from the complaint and compliance inspection conducted on March 27, 2023.

Based on observation and interview, the manager failed to ensure medication stored by an assisted living facility was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed a risk to the physical health and safety of residents with access to the medication.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed an unlocked cabinet in the kitchen above the oven. Inside the cabinet, the Compliance Officer observed a bottle of "NyQuil."

2. In an interview, E2 and E4 reported not knowing the medication had been there.

This is a repeat citation from the complaint and compliance inspection conducted on March 27, 2023, and the compliance inspection conducted on May 24, 2022.

Based on observation and interview, the manager failed to ensure the premises was free from a condition or situation that may have caused a resident or other individual to suffer physical injury. The deficient practice posed a risk to the health and safety of a resident.

Findings include:

1. During the environmental inspection of the facility, the Compliance Officer observed a mop handle and two hoses strewn across a walking path in the backyard, creating a tripping hazard.

2. In an interview, O1 acknowledged the tripping hazard, reporting facility personnel discouraged residents from going in the backyard during the summer.

Technical assistance was provided on this rule during the complaint and compliance inspection conducted on March 27, 2023.

Based on documentation review and interview, the health care institution failed to develop a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of the facility documentation revealed an undated document titled "FALL PREVENTION." The document stated " ...RECOVERY TRAINING FOR EMPLOYEES ...The manager will ensure that employees receive in service training regarding handling a resident that may have injuries after a fall. Documentation of training will be kept in resident files and documented in resident service plan." However, the training program did not include the initial training and continued competency training requirement.

2. In a joint interview, E2 and O1 acknowledged the facility's fall prevention and fall recovery training program did not include the initial training and continued competency training requirement.

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of Department documentation revealed the license for AL10734 was effective May 14, 2018.

2. A review of facility documentation revealed a policy and procedure manual dated April 31, 2018. However, documentation to indicate the policy and procedure manual had been reviewed and updated at least once every three years was not available for review.

3. In an interview, E2 acknowledged the policies and procedures had not been reviewed at least once every three years.

Based on documentation review, record review, and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance.

Findings include:

1. A review of facility documentation revealed a policy and procedure manual dated April 31, 2018. However, documentation to indicate the policy and procedure manual had been reviewed and updated at least once every three years was not available for review.

2. A review of facility documentation revealed a daily staffing schedule dated March 2023. However, the daily staffing schedules did not include documentation of E2, E3, and E4 working each day, including the hours worked.

3. A review of E2's personnel record revealed a valid fingerprint clearance card. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(2), was not available for review.

4. A review of E3's personnel record revealed a valid fingerprint clearance card. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review.

5. A review of E4's personnel record revealed a valid fingerprint clearance card. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review.

6. A review of R4's medical record revealed documentation dated within 90 calendar days before R4's date of admission, to include whether R4 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.

7. A review of R1's medical record revealed a service plan for directed care services dated in March 2023. R1's service plan revealed R1 required assistance with activities of daily living including draining of R1's indwelling catheter "every 2-4 HRS and PRN." However, documentation to indicate activities of daily living including draining of R1's indwelling catheter "every 2-4 HRS and PRN" were provided to R1 was not available for review.

8. A review of facility documentation revealed an incident report for R4 dated February 8, 2023. The incident report stated "Description of the Incident: [R4] started to have psychotic behavioral and was confused so we call 911 ..." However, the incident report did not document the actions taken by the caregiver or assistant caregiver and any action taken to prevent the accident, emergency, or injury from occurring in the future.

9. A review of the facility documentation revealed an undated document titled "FALL PREVENTION." The document stated " ...RECOVERY TRAINING FOR EMPLOYEES ...The manager will ensure that employees receive in service training regarding handling a resident that may have injuries after a fall. Documentation of training will be kept in resident files and documented in resident service plan." However, the training program did not include the initial training and continued competency training requirement.

10. In a joint interview, E2 and O1 acknowledged documentation required by Article 7 was not provided to the Department within two hours after a Department request.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1)(2), for three of four employees sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the personnel records during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

A.R.S. \'a7 36-411(C) Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card.

1. A review of E2's (hired in 2022) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(2) was not available for review.

2. A review of E3's (hired in 2023) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review.

3. A review of E4's (hired in 2023) personnel record revealed a valid fingerprint clearance card. However, documentation to indicate compliance with A.R.S. \'a7 36-411(C)(1)(2) was not available for review.

4. In a joint interview, E2 and O1 acknowledged E2's, E3's, and E4's fingerprint clearance cards were not verified. E2 and O1 acknowledged E3's and E4's compliance with A.R.S. \'a7 36-411(C)(2) was not available for review.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to include whether the individual required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse or physician assistant, for one discharged resident. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R4's (admitted in 2022) medical record revealed documentation dated within 90 calendar days before R4's date of admission, to include whether R4 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant was not available for review.

2. In an interview, E2 reported the required documentation was completed, however, E2 was unable to locate the documentation.

Based on record review and interview, the manager failed to ensure a caregiver documented the services provided in the resident's medical record, for one of three current residents sampled. The deficient practice posed a risk as services could not be verified as provided against a service plan, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's (admitted in 2021) medical record revealed a service plan for directed care services dated in March 2023. R1's service plan revealed R1 required assistance with activities of daily living including draining of R1's indwelling catheter "every 2-4 HRS and PRN." However, documentation to include draining of R1's indwelling catheter "every 2-4 HRS and PRN" was not available for review.

2. In an interview, E2 reported caregivers on duty drained R1's indwelling catheter, however, caregivers on duty had not documented the service provided to R1.

3. In a joint interview, E2 and O1 acknowledged documentation to indicate services were provided to R1 were not documented.

Based on observation and interview, the manager failed to ensure medication was stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage. The deficient practice posed an accessibility risk to residents who were not prescribed the accessible medication.

Findings include:

1. The Compliance Officer observed two ambulatory residents on the premises.

2. The Compliance Officer observed Loperamide 1MG/7.5 ML SOLN, belonging to R1, in an unlocked kitchen refrigerator.

3. The Compliance Officer observed what appeared to be an unlocked lunch box in an unlocked kitchen refrigerator. The lunchbox contained no fewer than eleven insulin injections.

4. The Compliance Officer observed multiple pharmacy prepared blister packs in an unlocked laundry room.

5. In a joint interview, E2 and O1 acknowledged the medications were not stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage.

This a repeat citation from the compliance inspection conducted on May 24, 2022.

Based on documentation review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the actions taken by the caregiver or assistant caregiver and any action taken to prevent the accident, emergency, or injury from occurring in the future, for one discharged resident who had an accident, emergency, or injury resulting in the resident needing medical services. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of facility documentation revealed an incident report for R4 dated February 8, 2023. The incident report stated "Description of the Incident: [R4] started to have psychotic behavioral and was confused so we call 911 ..." However, the incident report did not document the actions taken by the caregiver or assistant caregiver and any action taken to prevent the accident, emergency, or injury from occurring in the future.

2. In an interview, E2 and O1 acknowledged the incident report for R4 did not contain actions taken by the caregiver or assistant caregiver and any actions taken to prevent the accident, emergency, or injury from occurring in the future.