AHADI CARE HOME

Based on observation 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. When the Compliance Officer arrived, E2 and E3 were the only personnel members working at the facility.

2. During the environmental tour, the Compliance Officer observed there was a personnel work schedule posted for the month of September. However, E3 was not on the personnel work schedule posted.

3. In an interview, E4 acknowledged documentation was not maintained of the caregivers and assistant caregivers working each day, including the hours worked.

Based on documentation review, 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), for two of three personnel sampled. The deficient practice posed a risk to the health and safety of residents as there was no evidence to show E2 and E3 were fit to work at the assisted living facility.

Findings include:

1. A.R.S. \'a7 36-411(C)(1) states: "1. Owners shall make documented, good faith efforts to: 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. A review of E2's and E3's personnel records revealed no documentation of evidence to indicate a good faith effort to contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution.

3. In an interview, E4 acknowledged E2's and E3's, personnel records did not include the documentation required in A.R.S. \'a7 36-411(C)(1). E3 acknowledged the reference checks were not done.

Based on record review and interview, the manager failed to ensure a written service plan was reviewed and updated at least once every three months, for one of two residents sampled who received directed care services. The deficient practice posed a risk as a service plan reinforces and clarifies services to be provided to a resident.

Findings include:

1. A review of R2's medical record revealed a written service plan for directed care services dated May 26, 2024. However, a service plan after May 26, 2024 was not available for review.

2. In an interview, E4 and E5 acknowledged R2 received directed care services and the service plan was not updated at least once every three months.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement the disaster plan.

Findings include:

1. A review of the July 2024 personnel schedule revealed three shifts; 6 AM - 6 PM and 6 PM - 6 AM.

2. A review of the facility's employee disaster drills revealed the following drills;
- July 10, 2024, at 3:00 PM
- June 28, 2024, at 11:50 AM
- March 10, 2024, at 3:00 PM
- January 10, 2024, at 3:00 PM
- October 02, 2023, at 6:45 AM
- September 10, 2023, at 6:46 PM
- April 15, 2023, at 10:00 AM

3. In an interview, E4 and E5 acknowledged the employee disaster drills were not conducted on each shift at least once every three months.

Based on observation, record review, and interview, the manager failed to designate, in writing, a caregiver who was present on the facility's premises and accountable for the facility when the manager was not present as the manager's designee.

Findings include:

1. When the surveyor arrived at the facility, the manager was not present. The conspicuously posted assigned manager's designee list did not include E2's and E3's names who were the only caregivers working at the facility at the beginning of the inspection. Review of E2's and E3's personnel records revealed both employees were caregivers. E2 was hired on April 1, 2023 and E3 was hired on March 1, 2023.

2. In an interview, after E1, E4, and E5 arrived to the facility, they acknowledged E2 and E3 were not included on the manager's designee posted list nor any place else.

This is a repeat deficiency from the compliance inspection conducted on May 2, 2022.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a locked room, closet, cabinet, or self-contained unit; which posed a health and safety risk.

Findings include:

1. During a facility tour, E4 and the compliance officer observed in the facility's unlocked kitchen refrigerator in the bottom drawer of the refrigerator there was a plastic container with a rubber band around it containing flextouch insulin. Also in a ziplock bag on top of this plastic container there was stored flextouch insulin. Also an insulin flextouch pen was laying loose on top of the ziplock bag, There were twenty-one flex pens of Novolog insulin and three flex pens of Levemir insulin stored unlocked.

2. In an interview, E1 and E4 acknowledged the unlocked medications that were not stored in a self-contained unit.

Based on observation and interview, the manager failed to ensure soiled linen stored by the facility was stored in a closed container, which posed a health risk.

Findings include:

1. During a facility tour, E4 and the compliance officer observed in the facility's laundry room there was a pile of soiled linen laying on the floor of the laundry room.

2. In an interview. E4 reported the linen was soiled and acknowledged it was not being stored in a closed container.