PRESCOTT VALLEY ASSISTED LIVING

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.

Findings include:

1. A review of R2's medical record revealed a service plan dated in 2023, for directed care services. The service plan did not include the signature of R2's representative to show the service plan was developed with assistance and review by R2's representative.

2. A review of R1's medical record revealed an activities of daily living (ADL) document for March 2023. However, the ADL document did not indicate R1 received assistance with bathing/showering as described in R1's service plan.

3. A review of the Arizona Department of Public Safety fingerprint clearance card verification website revealed E2's fingerprint clearance card status stated "Not Valid."

4. In an interview, E1 acknowledged documentation indicating compliance with the aforementioned requirements was not provided within two hours after a Department request

Based on record review and interview, the manager failed to ensure a resident had a written service plan developed with assistance and review from the resident or resident's representative, for one of two residents sampled. The deficient practice posed a risk as the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R2's medical record revealed a service plan dated in 2023, for directed care services. The service plan did not include the signature of R2's representative to show the service plan was developed with assistance and review by R2's representative.

2. In an interview, E1 acknowledged the service plan for R2 was not signed to indicate the service plan was developed with assistance and review by R2's representative.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as the services provided were unable to be verified and the required documentation was not provided during the inspection, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request.

Findings include:

1. A review of R1's medical record revealed a service plan dated in 2023 for directed care services. The service plan stated "ADL's...bathing-level of care...full assistance...bathing-full assistance daily @ as needed. 1 person(s) required for this task. Provide full assistance bathing/showering..."

2. A review of R1's medical record revealed an activities of daily living (ADL) document for March 2023. However, the aforementioned service was not included on the ADL, or documented as provided to R1.

3. In an interview, E1 reported R1 received bathing/showering assistance as noted in R1's service plan, and acknowledged the aforementioned service was not documented in R1's medical record as provided.