BROADWAY PROPER SENIOR LIVING

Based on documentation review, record review, and interview, the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery.

Findings include:

1. A review of facility documentation revealed a policy and procedure, last reviewed August 9, 2023, titled, "Fall Risk Management Policy | HW 006." This policy stated, "Staff will complete training during hire and annually specific to fall prevention." However, the policy and procedure did not cover fall recovery.

2. A review of E4's personnel record revealed E4 was hired in February of 2022. E4's personnel record revealed E4 had completed an online course titled, "Identifying Fall Risk in Assisted Living," on December 28, 2022. However, documentation of initial training in fall prevention and documentation of initial and continued competency training in fall recovery were not available for review.

3. A review of E5's personnel record revealed E5 was hired in December of 2021. A review of a document titled, "In-Service Attendance," revealed E5 had received a, "Fall Prevention," in-service on April 26, 2022. E5's personnel record revealed E5 had completed an online course titled, "Identifying Fall Risk in Assisted Living," on December 24, 2022. However, documentation of initial training in fall prevention and documentation of initial and continued competency training in fall recovery were not available for review.

4. A review of E6's personnel record revealed E6 was hired in June of 2023. However, E6's personnel record revealed E6 had been assigned but had not yet completed an online course titled, "Identifying Fall Risk in Assisted Living." Documentation of initial training in fall prevention and fall recovery were not available for review.

5. A review of E7's personnel record revealed E7 was hired in August of 2023. E7's personnel record revealed E7 had completed an online course titled, "Identifying Fall Risk in Assisted Living," on November 26, 2023. However, documentation of initial training in fall prevention and fall recovery were not available for review.

6. A review of E8's personnel record revealed E8 was hired in December of 2022. E8's personnel record revealed E8 had completed an online course titled, "Identifying Fall Risk in Assisted Living," on January 1, 2023. However, documentation of initial and continued competency training in fall recovery were not available for review.

7. A review of E9's personnel record revealed E9 was hired in May of 2020. A review of a document titled, "In-Service Attendance," revealed E10 had received a, "Fall Prevention," in-service on April 26, 2022. E9's personnel record revealed E9 had completed an online course titled, "Identifying Fall Risk in Assisted Living," on December 10, 2022. However, documentation of initial training in fall prevention and documentation of initial and continued competency training in fall recovery were not available for review.

8. A review of E10's personnel record revealed E10 was hired in February of 2023. However, E10's personnel record revealed E10 had been assigned but had not yet completed an online course titled, "Identifying Fall Risk in Assisted Living." Documentation of initial training in fall prevention and documentation of initial and continued competency training in fall recovery were not available for review.

9. A review of E11's personnel record revealed E11 was hired in September of 2023. However, E11's personnel record revealed E11 had been assigned but had not yet completed an online course titled, "Identifying Fall Risk in Assisted Living." Documentation of initial training in fall prevention and fall recovery were not available for review.

10. In an interview, E1, E2, and E3 acknowledged the health care institution had not developed and administered a training program for all staff regarding fall prevention and fall recovery.

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for ten of ten employees reviewed. The deficient practice posed a risk if the employee was a danger to a vulnerable population.

A.R.S. \'a7 36-411 states, "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work.

B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section.

C. Owners shall make documented, good faith efforts to:

1. 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. Verify the current status of a person's fingerprint clearance card.

D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service.

E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked.

F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card.

G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety.

H. For the purposes of this section:

1. "Direct supportive services":

(a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including:

(i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair.

(ii) Assistance with self-administration of medication.

(iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room.

(iv) Transportation services, including van services.

(b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution.

2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised.

3. "Home health services" has the same meaning prescribed in section 36-151."

Findings include:

1. A review of E4's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E4's fitness to work in a residential care institution were not available for review.

2. A review of E5's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E5's fitness to work in a residential care institution were only available for one prior employer.

3. A review of E6's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E6's fitness to work in a residential care institution were not available for review. E6's personnel file included two documented references, however, both references indicated the person contacted was a co-worker.

4. A review of E7's personnel record revealed an application for a fingerprint card dated within 20 working days of employment, a valid fingerprint clearance card and verification of the current status of a fingerprint clearance card were not available for review. E7 was determined to have a valid fingerprint clearance card, however, E7's personnel file did not include the required documentation.

5. During the on-site inspection, E7 sent a text message to E2 containing the card number of E7's fingerprint clearance card. Online verification confirmed E7's fingerprint clearance card was valid.

6. A review of E8's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E8's fitness to work in a residential care institution were not available for review.

7. A review of E9's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, documented, good faith efforts to contact previous employers to obtain information or recommendations that may have been relevant to E9's fitness to work in a residential care institution, and documented verification of the current status of E9's fingerprint clearance card were not available for review.

8. A review of E10's personnel record revealed a valid fingerprint clearance card and an application listing prior employers. However, documented, good faith efforts to contact previous empl

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident that covered orientation for employees and volunteers.

Findings include:

1. The Compliance Officer's requested to review the facilities' policy and procedure covering orientation. However, a policy covering orientation was not provided for review. Instead, a policy titled, "Employee Training & In-Service," dated 2014, was provided for review.

2. A review of the facility's policies and procedures revealed a policy titled, "Employee Training & In-Service," dated 2014. The policy covered skills verification and required training and did not cover orientation. Additionally, the policy covered, "non-licensed employees," a "nursing assistant," a "nursing home facility," and "Federal law requirements for Long Term Care Facilities," and did not cover assisted living facilities or certified caregivers. The policy appeared to be for a skilled nursing or long term care facility.

3. A review of eight sampled caregiver records revealed documentation of orientation was not available. Four of the eight sampled personnel records included a list of job duties and responsibilities signed by the personnel member shortly after hire and four of the eight sampled personnel records included no initial documentation which might be related to orientation.

4. In an interview, E3 reported there is a on-the-job initial training for every caregiver which includes orientation to the facility and orientation to the rules and responsibilities of the position, and E3 reported the signed job responsibilities form had been used to document orientation. E3 reported there are new policies and procedures at the facility and E3 was unaware what specific documentation of orientation was required by the new policies, if any.

5. In an interview, E1, E2, and E3 acknowledged the provided policy and procedure did not specifically cover orientation for employees and volunteers and acknowledged documentation of orientation was not consistent in the sampled personnel records.

Based on documentation review, record review, observation, and interview, the manager failed to implement policies and procedures to protect the health and safety of a resident to cover cardiopulmonary resuscitation (CPR) training for applicable employees to include the method and content of CPR training, including a demonstration of the employee's ability to perform cardiopulmonary resuscitation, for one of ten sampled employees. The deficient practice posed a risk to the health and safety of residents if employees were unable to perform life saving measures in the event of an emergency.

Findings include:

1. A review of the facility's policies and procedures revealed a policy titled, "First-Aid Policy," dated 2014, which stated, "Community will maintain at least one CPR/First-Aid certified staff onsite at all times. Health and Wellness staff are required to be CPR/First-Aid certified." However, this policy did not cover the requirements in R9-10-803(M), R9-10-806(A)(10), and did not include the method and content of cardiopulmonary resuscitation training, which includes a demonstration of the employee's or volunteer's ability to perform cardiopulmonary resuscitation; the qualifications for an individual to provide cardiopulmonary resuscitation training; the time-frame for renewal of cardiopulmonary resuscitation training; and the documentation that verifies that the employee or volunteer has received cardiopulmonary resuscitation training.

2. A review of E12's personnel record revealed E12 had been hired as caregiver in October of 2023.

3. A review of E12's personnel record revealed CPR training certification from, "National CPR Foundation," an online-only CPR training program which provided certification without requiring a demonstration of E12's ability to perform CPR.

4. In an interview, E1, E2, and E3 acknowledged the facility's policies and procedures did not cover all required subsections of the rule and acknowledged E12's CPR training certification had not included an demonstration of E12's ability to perform CPR.

Based on documentation review, record review, and interview, the manager failed to ensure a caregiver provided verifiable documentation of completion of a caregiver training program approved by the Department or the Board of Examiners for Nursing Care Institution Administrators and Assisted Living Facility Managers (NCIA Board), for one of eight caregivers sampled. The deficient practice posed a risk if the individual was not qualified to provide the required services.

Findings include:

1. A review E6's personnel record revealed E6 was hired as a caregiver in June of 2023.

2. A review of E6's personnel record revealed a copy of a caregiver training certificate issued on December 21, 2012 by "Cactus Wren Caregiver and Managerial Training."

3. A review of E6's personnel record revealed an application for employment. The application stated E6 had completed high school and college in a foreign country, earning a bachelors degree. The application listed six prior employers as follows:
- June 2013 to May 2016, "caregiving" in a foreign country - reason for leaving pregnancy;
- 2018 to 2019, "caregiving" in a foreign country, reason for leaving, "coming back to USA;"
- March 2020 to January 2022, "shipping, stocker" for a temporary agency in Tucson;
- February 2021 to December 2021, "Janitor and warehouse," in Tucson, and
- February 2022 to June 2023, "Certified Caregiver," for a staffing agency in Tucson.

4. A review of E6's personnel record revealed a two year US Employment Authorization card, category A03 (Refugee) dated December 2019 with a marked expiration of December 2021.

5. A review of E6's personnel record revealed no ancillary documentation establishing E6's presence in the US at the time the caregiver certification was issued.

6. In an interview, E1, E2, and E3 reported E6 had been in the US prior to returning to a foreign country for several years. E1, E2, and E3 acknowledged the certification was unverifiable and E6's qualifications could not be verified by the Department without supporting documentation showing E6 was likely to have attended the caregiving school at the time it was issued.

Based on record review, documentation review, and interview, the manager failed to ensure, five of eight sampled caregiver personnel records sampled contained documentation indicating a caregiver or assistant caregiver's skills and knowledge were verified and documented before the caregiver provided physical health services. The deficient practice posed a risk if the employees did not have the skills and knowledge necessary to meet a resident's needs.

Findings include:

1. A review of E6's, E7's, E11's, E12's and E13's personnel records revealed documentation showing each caregivers' skills and knowledge were verified prior to providing physical health services was not available for review.

2. In an interview, E1, E2, and E3 acknowledged the personnel records provided for E6, E7, E11, E12, and E13 did not include documentation of verification of skills and knowledge.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted which included the requirements in R9-10-807(B)(1-2) for one of ten resident records reviewed.

Findings include:

1. A review of R2's medical record (admitted April 2023) revealed no documentation dated within 90 calendar days before R2's date of admission, to include whether R2 required continuous medical services, continuous nursing services, intermittent nursing services or restraints; signed and dated by a physician, registered nurse practitioner, registered nurse, or physician assistant.

2. In an interview, E1 acknowledged R2 did not submit the required documentation.