MULBERRY ASSISTED LIVING-NIDO

Based on documentation review and interview, the manager failed to implement a plan for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled, "Policy on Quality Management." The policy stated,
"I. The Team shall:
1. Conduct a self-audit on the Facility Grounds at least once a year. Make notes on any findings and corrective actions when necessary.
2. Conduct a self-audit on the resident's file every six (6) months. Make notes on any findings and the necessary corrective actions.
3. Conduct a self-audit on personnel files and review the skills and knowledge of the caregivers every six (6) months to ensure that caregivers will be able to provide the services offered by the facility as specified in the Scope of Services and meet the needs of the residents.
4. Conduct a self-audit on miscellaneous files every six (6) months. Make notes on any findings and corrective actions when necessary.
5. Match residents' medications with the resident's doctor's orders and the Medication Administration Record every end of the month.
6. Identify, document and evaluate incidents and accidents (e.g. falls, medication errors, adverse reactions to medications including opioid treatments and deaths resulting from overdose of opioid treatments, etc.) every six (6) months to address identified risks to health, safety and welfare of residents. A tally of these reports shall be made by the Manager for easy identification of areas of concern...III. A report of the results of these meetings shall be submitted by the Manager to the Governing Authority and a copy of which shall be kept in the facility and filed for at least 12 months."

2. The Compliance Officer requested the facility's quality management documentation for review.

3. In an interview, E1 reported the facility has not implemented their quality management program. E1 reported there was no documentation available for review.

4. In an interview, E1 acknowledged the quality management program had not been implemented in the facility.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregivers working each day, including the hours worked by each. The deficient practice posed a risk as there was no documentation to identify the staff that was present each day to ensure the health and safety of residents.

Findings include:

1. Upon arrival, the Compliance Officer observed E2, E3, and E4 working at the facility.

2. The Compliance Officer requested the employee schedules for the last 12 months as well as the current schedule for review.

3. A review of the September 2024 employee schedule revealed E3 and E4 were not listed on the schedule at all, even though they were present and providing services on the day of the inspection.

4. In an interview, E1 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day. E1 reported E3 recently started working at the facility but was leaving the next day and would be gone for a month. E1 reported E4 typically worked at another home owned by E1 and was on a trial period at this home.

Based on documentation review, record review, and interview, the manager failed to ensure a complete personnel record was available for two of two employees reviewed. The deficient practice posed a risk as required information could not be verified for E3 and E4.

Findings include:

1. Upon arrival, the Compliance Officer requested all personnel records for review.

2. A review of E3's personnel record revealed the following required information was not documented in E3's personnel record:
-Qualifications, including skills and knowledge applicable to the individual's job duties; and
-Compliance with A.R.S. \'a7 36-411(C)(1);

3. In an interview, the Compliance Officer requested E4's personnel record for review. E1 reported E4 did not have a personnel file on-site. E1 was unable to provide the Compliance Officer with any documentation for review.

4. In an interview, E1 acknowledged E3's and E4's personnel records were incomplete or not available for review. E1 reported E3 recently started working at the facility but was leaving the next day and would be gone for a month. E1 reported E4 typically worked at another home owned by E1 and was on a trial period at this home.