MAELEE CARE HOME LLC

Based on documentation review, record review and interview, the health care institution failed to administer 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 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 undated policy and procedure titled "Fall Prevention and Recovery Training." The policy and procedure stated " ...Maelee Care Homes LLC ...has developed and administers a training program for all caregiving staff ...The training program requires initial training and continued competency review on an annual basis in fall prevention and fall recovery ..."

2. A review of E1's (hired in 2020) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

3. A review of E2's (hired in 2020) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

4. A review of E3's (hired in 2022) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

5. A review of E4's (hired in 2021) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

6. In an interview, E1 acknowledged the facility had not administered a training program for all staff regarding fall prevention and fall recovery.

Based on 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 as the following documentation was not provided for review: E1's, E2's, and E4's completed in-service education; and E1's, E2's, E3's, and E4's initial training in fall prevention and fall recovery.

Findings include:

1. A review of E1's (hired in 2020) personnel record revealed completed in-service education was not available for review.

2. A review of E2's (hired in 2020) personnel record revealed completed in-service education was not available for review.

3. A review of E4's (hired in 2021) personnel record revealed completed in-service education was not available for review.

4. A review of E1's (hired in 2020) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

5. A review of E2's (hired in 2020) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

6. A review of E3's (hired in 2022) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

7. A review of E4's (hired in 2021) personnel record revealed initial training in fall prevention and fall recovery was not available for review.

8. In an interview, E1 acknowledged the aforementioned documentation was not provided for review within two hours after a Department request.

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's completed in-service education, for three of four caregivers 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:

1. A review of facility documentation revealed a policy and procedure titled "In-Service Education" (dated February 17, 2020). The policy and procedure stated " ...Each manager and caregiver will as a minimum complete at least 12 hours of ongoing training ...every 12 months from the starting date of employment ..."

2. A review of E1's (hired in 2020) personnel record revealed completed in-service education, every 12 months from the starting date of employment, was not available for review.

3. A review of E2's (hired in 2020) personnel record revealed completed in-service education, every 12 months from the starting date of employment, was not available for review.

4. A review of E4's (hired in 2021) personnel record revealed completed in-service education was not available for review.

5. In an interview, E1 acknowledged E1's, E2's, and E4's in-service education required by the facility's policy and procedure was not available for review.