Evidence/Findings:
Based on record review, documentation 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 as the following documentation was not provided for review: documentation designating E2; documentation of CPR demonstration for E2; documentation of skills and knowledge for E2; documentation of the caregivers and assistant caregivers working each day to include the hours worked for February 2023; E2's starting date of employment; documentation of experience for E2; documentation of completed orientation for E2; in-service education for E3; documentation of the requirements in R9-10-807(B)(1)(a)(b) for R1 and R2; documentation of the requirement in R9-10-808(A)(5)(a) for R1 and R2; documentation of the requirement in R9-10-808(A)(5)(b) for R1 and R2; documentation of services provided to R1, R3, and R4; documentation of planned activities at least one week in advance; documentation of date of termination of residency for R3 and R4; documentation of notification of the availability of vaccination for influenza and pneumonia for R1 and R2; documentation of the requirements in R9-10-814(B)(2)(b) for R1; documentation of compliance with A.R.S. \'a7 36-411(C)(1) for E2; and evidence of a fall prevention and fall recovery training program.
Findings include:
1. A review of E2's personnel record revealed a CPR and first aid training (dated August 30, 2022). The document stated "RECOGNITION OF COMPLETION [E2] has successfully completed ASHI Online Training for: CPR, AED, and Basic First Aid All Ages (G2015)-DC (Blended)...Blended learning consists of computer-based, online lessons combined with hands-on skill practice and performance evaluation. This document confirms that the above-named individual has completed the required online lessons and is now eligible for hands-on skill practice and performance evaluation by a current and properly authorized ASHI Instructor." However, E2's CPR did not include the requirements and the policy and procedure was not implemented.
2. A review of E2's personnel record revealed a document titled "EMPLOYEE QUALIFICATION AND SKILLS" (undated). The document was initialed by E2; however, the "Signature of the Owner / Manager" and "Date" sections were left blank.
3. A review of facility documentation revealed documentation of the caregivers and assistant caregivers working each day, including the hours worked by each for February 1, 2023 through February 7, 2023 was not available for review.
4. A review of E2's personnel record revealed E2's starting date of employment was not available for review.
5. A review of E2's personnel record revealed documentation of experience applicable to E2's job duties was not available for review.
6. A review of E2's personnel record revealed a document titled "Employee Orientation Checklist" (undated). The document was initialed by E2; however, the "Signature of the Owner / Manager" and "Date" sections were left blank.
7. A review of E3's personnel record revealed documentation of completion of in-service education for 2022 was not available for review.
8. A review of R1's medical record revealed documentation 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 was not available for review.
9. A review of R2's medical record revealed documentation 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 was not available for review.
10. A review of R1's medical record revealed a current service plan (dated in December 2022) for directed care services. However, the service plan was not signed and dated by the resident's representative.
11. A review of R2's medical record revealed the following written service plans for personal care:
-May 2021;
-November 2021;
-May 2022; and
-November 2022.
The service plan was signed and dated by the power of attorney (POA) on October 19, 2021. However, updated service plans were not signed and dated by the resident's POA.
12. A review of R1's medical record revealed a current service plan (dated in December 2022 ) for directed care services. However, the service plan was not signed and dated by the manager.
13. A review of R2's medical record revealed a current service plan (dated in November 2022) for personal care services. However, the service plan was not signed and dated by the manager.
14. A review of R1's medical record revealed a current service plan (dated in December 2022) for directed care services. The service plan stated the following services were to be provided to R1:
-"Mobility...requires positioning...Transfer assistance bedbound";
-Hygiene/Grooming/PRN...Brush teeth...Daily &/or PRN; Clean nails PRN; Assist Dressing; Comb hair daily; Skin care PRN; Check pressure areas PRN";
-"Elimination...Incontinent; Change every two hours/PRN; Peri Care PRN."
15. A review of R1's medical record revealed an activities of daily living (ADL) document for January 1-30 2023. However, the following services were not documented on January 1-31, 2023:
-Repositioning; and
-Incontinent care.
16. A review of R3's medical record revealed a service plan (dated in November 2022) for personal care services. The service plan stated the following services were to be provided to R3:
-"Elimination...Incontinent...Both; Use disposable undergarments; Change every two hours/PRN; Peri Care PRN."
17. A review of R3's medical record revealed an ADL document for December 1-9, 2022. However, the following service were not documented on December 1-9, 2022:
-Incontinent care.
18. A review of R4's medical record revealed a service plan (dated in August 2022) for personal care services. The service plan stated the following services were to be provided to R4:
-"Mobility...Transfer assistance 1x assist";
-"Bathing CG assist...shower; complete bath 2 X week/PRN; Wash Hair; With shower; Peri care; After each disposable change";
-"Hygiene/Grooming/PRN...Brush teeth; Daily &/or PRN; Clean nails PRN; Comb hair daily; Skin care PRN; Check pressure areas PRN";
-"Elimination...Incontinent...Both; Uses disposable undergarments; Change every two hours/PRN; Peri care PRN."
19. A review of R4's medical record revealed an ADL document for November 1-30, 2022. However, the following services were not documented on November 1-30, 2022.
-Dressing;
-Oral care;
-Skin care; and
-Incontinent care.
20. A review of R4's medical record revealed an ADL document for December 1-9, 2022. However, the following services were not documented on December 1-9, 2022:
-Dressing;
-Oral care;
-Skin care; and
-Incontinent care.
21. A review of R3's medical record revealed R3's date of termination of residency was not available for review.
22. A review of R4's medical record revealed R4's date of termination of residency was not available for review.
23. A review of R1's medical record revealed documentation of notification of R1 of the availability of vaccination for influenza and pneumonia, on a yearly basis, was not available for review.
24. A review of R2's medical record revealed documentation of notification of R2 of the availability of vaccination for influenza and pneumonia, on a yearly basis, was not available for review.
25. A review of R1's medical record revealed documentation to demonstrate the requirements in R9-10-814(B)(2)(b) w
Summary:
The following deficiencies were found during the on-site compliance inspection conducted on March 25, 2025: