HAPPY AND HEALTHY ASSISTED LIVING

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. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not availabe during the inspection, and the licensee did not provide the documentation within two hours after a Department request.

Findings include:

1. A review of facility documentation revealed an undated document titled "FALL PREVENTION AND RECOVERY." The document included a training program for fall prevention and fall recovery, however, the document did not include a training program for fall prevention and fall recovery training program for all staff.

2. A review of the facility's policies and procedures revealed a policy titled "In-Service Education" dated August 26, 2021. However, evidence of a fall prevention and fall recovery training program for all staff was not available for review.

3. A review of E2's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery.

4. A review of E3's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery.

5. In an interview, E1 acknowledged the facility did not administer a training program for all staff regarding fall prevention and fall recovery.

Based on documentation review, observation, record review, and interview, the manager failed to establish and document policies and procedures to protect the health and safety of a resident to cover qualification, including required skills and knowledge for employees and volunteers. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees, the Department was unable to determine substantial compliance as the documentation was not available during the inspection, and the licensee did not provided the documentation within two hours after a Department request.

Findings include:

1. A review of Department documentation revealed the perpetual license for AL11736 was effective December 18, 2020.

2. A review of the facility's policies and procedures revealed a policy titled "4. Facility job descriptions, duties, and qualifications." dated August 26, 2021. The policy stated "...5. All of the above staff must have: a. A file that is maintained on the premises for each employee or volunteer and containing the following:...B. Include: a. The specific skills and knowledge necessary for the caregiver or assistant caregiver to provide the expected assisted living services..." However, the policy did not include required skills and knowledge for caregivers.

3. In an interview, E1 acknowledged the policies and procedures to cover qualifications, including required skills and knowledge for a caregiver were not available for review.

Based on record review and interview, the administrator 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 licensee did not provide the following for review: policies and procedures to cover qualifications, including required skills and knowledge; E2's and E3's qualifications, including skills and knowledge, applicable to E2's and E3's job duties; and a training program for all staff regarding fall prevention and fall recovery.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled "4. Facility job descriptions, duties, and qualifications" dated August 26, 2021. The policy stated "...5. All of the above staff must have: a. A file that is maintained on the premises for each employee or volunteer and containing the following:...B. Include: a. The specific skills and knowledge necessary for the caregiver or assistant caregiver to provide the excepted assisted living services..." However, the policy did not include qualification, including required skills and knowledge for caregivers.

2. A review of E2's (hired as a manager) personnel record revealed the record did not include evidence of E2's qualifications, including skills and knowledge applicable to E2's job duties.

3. A review of E2's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery.

4. A review of E3's personnel record revealed the record did not include documentation of initial training or continued competency training in fall prevention and fall recovery.

5. In an interview E1 acknowledged documentation required by this Article 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 the individual's qualifications, including skills and knowledge applicable to the individual's job duties, for one of three personnel records sampled. The deficient practice posed a risk if E2 were unable to meet a resident's needs, the Department was unable to determine substantial compliance as the documentation was not availabe in the personnel record during the inspection, and the licensee did not provide the documentation within two hours after a Department request.

Findings include:

1. A review of E2's (hired in 2020) personnel record revealed E2 was hired as a manager. However, documentation of E2's qualifications, including skills and knowledge applicable to E2's job duties were not available for review.

2. In an interview, E1 reported E2's skills and knowledge were verified and documented, however, E1 could not locate the documentation. E1 acknowledged the personnel record for E2 did not include documentation of E2's qualifications, including skills and knowledge applicable to E2's job duties.