CANYON CREEK ASSISTED LIVING & MEMORY CARE

Based on record review, documentation 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 in-service education for employees and volunteers, for three of three employees requiring in-service education. The deficient practice posed a risk as the policy did not meet the rule requirement of having documented requirements of in-service education as the policy gave no minimum requirement of each topic.

Findings include:

R9-10-101.116. "In-service education" means organized instruction or information that is related to physical health services or behavioral health services and that is provided to a medical staff member, personnel member, employee, or volunteer.

1. A review of E1's personnel record revealed E1 was a caregiver and owner of the facility.

2. A review of E2's personnel record revealed E2 was a caregiver.

3. A review of E3's personnel record revealed E3 was a caregiver and owner of the facility.


4. A review of E1's, E2's, and E3's personnel records revealed no documentation of completed in-service education.

5. A review of the facility's policies and procedures revealed an undated policy titled, "Employee Orientation and Ongoing Training." The policy stated, "The manager/owner of the facility shall confirm that each caregiver and manager completes as many hours as required by the state of ongoing training every 12 months from the starting date of employment. CEU's are the responsibility of the employee and documentation of completion must be given to the manager. Failure to do so may result in termination of employment.

-The training shall include:
Supervisory Care: Training pertaining to general supervision & intervention in crisis. (no minimum)
Personal Care: Personal Resident Care or Basic Caregiver Skills (no minimum)
Directed Care: Training pertaining to residents who are unable to direct self-care (no minimum)
The manager/owner of the facility shall confirm that each manager completes ongoing training per NCIA [Nursing Care Institution Administrators and Assisted Living Managers] and ADHS [Arizona Department of Health Services] guidelines. (Reference R9-10-806"

6. In an interview, E2 acknowledged the facility did not establish, document, or implement a policy to cover in-service education for employees and volunteers, as the aforementioned policy did not include minimum requirements for in-service education for employees or volunteers.

Based on documentation review, record review, and interview, the manager failed to ensure an assistant caregiver's skills and knowledge were verified and documented before the assistant caregiver provided physical health services, and according to policies and procedures, for one of one assistant caregiver sampled. The deficient practice posed a risk if the assistant caregiver was unable to meet a resident's needs.

Findings include:

1. A documentation review revealed an undated policy and procedure titled "Caregiver Job Description.". The policy and procedure stated, "A caregiver will be required to provide the assisted living facility with verification of the type and duration of education or experience that may allow the caregiver to acquire the specific skills and knowledge for them to provide the expected assisted living services, behavioral health services, or behavioral care ...A caregiver ...will complete a skills checklist to ensure that they have experience and knowledge to complete the requirements of the job ...Skills will be verified during initial interview and again during orientation if hired."

2. A review of E4's personnel record revealed a document titled, "Caregiver Practical Skills Checklist," dated February 3, 2023. The document indicated the checklist was completed for Greenfield Assisted Living Home by an unknown individual. The record also included a blank, undated document titled, "Employee Assessment." The document stated, "The following are a list of skills required prior to hiring ...The above named employee/prospective caregiver has satisfactorily demonstrated competency in performing all the skills listed." The manager's signature and date signed fields were blank. Near the bottom of the document it was stated, "Canyon Creek Assisted Living & Memory Care Gilbert, AZ."

3. A documentation review revealed a personnel schedule dated May 8-14, 2023. The daily staffing schedule indicated E4 was scheduled to work 7:00 am-7:00 pm on Monday through Sunday.

4. A documentation review revealed a personnel schedule dated October 2022. The daily staffing schedule indicated E5 was scheduled to work alone during the night shift on the following dates: 1st, 2nd, 7th, 8th, 11th, 15th, 17th, 18th, 21st, 22nd, 25th, 26th, 29th, and 31st.

5. A review of E5's personnel record revealed no documentation demonstrating the manager verified E5's skills and knowledge before E5 provided assisted living, behavioral health, or behavioral care services and according to policies and procedures.

6. In an interview, E1, E2, and E3 reported not knowing the manager needed to verify the skills and knowledge of individuals hired through an agency. Regarding E4's personnel record missing verification of skills and knowledge, E2 indicated the facility's policies and procedures allowed for another agency to complete the verification of skills.

7. In an interview, E2 indicated E5's skills and knowledge were verified during E5's interview and orientation. However, no documentation was made available to review within the required two-hour time frame after the Department's request.

Based on documentation review and interview, the manager failed to ensure that as part of the policies required in R9-10-803(C)(1)(h), a plan was documented to ensure that the manager or caregiver was available as back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services.

Findings include:

1. A review of the facility's undated policies and procedures revealed they did not include the policy required in R9-10-803(C)(1)(h), a plan to document a manager or caregiver was available as back-up to provide assisted living services to a reside if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services.

2. A review of the facility's documentation revealed a staff schedule for October 2022. The staff schedules did not include documentation of a back-up personnel member.

3. In an interview, E2 reported the facility had established a procedure to ensure the manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. However, E2 acknowledged the procedure was not documented.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)(1-10) for two of two sampled residents admitted before the change of ownership. The deficient practice posed a risk if the resident was not informed of the terms of residency.

Findings include:

1. A review of R1's medical record revealed a residency agreement dated October 29, 2021. However, a change of ownership occurred on May 12, 2022 and a new residency agreement between R1 and the new owners was required.

2. A review of R2 ' s medical record revealed a residency agreement dated January 16, 2020. However, a change of ownership occurred on May 12, 2022, and a new residency agreement between R2 and the new owners was required.

3. In an interview, E3 indicated there was no need for R1 and R2 to sign new residency agreements because the name of the facility did not change with the change of ownership.