Rule/Regulation Violated:
C. A manager shall ensure that a personnel record for each employee or volunteer:
1. Includes:
a. The individual's name, date of birth, and contact telephone number;
b. The individual's starting date of employment or volunteer service and, if applicable, the ending date; and
c. Documentation of:
i. The individual's qualifications, including skills and knowledge applicable to the individual's job duties;
ii. The individual's education and experience applicable to the individual's job duties;
iii. The individual's completed orientation and in-service education required by policies and procedures;
iv. The individual's license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures;
v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115;
vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8);
vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures;
viii First aid training, if required for the individual in this Article or policies and procedures; and
ix. Documentation of compliance with the requirements in A.R.S. § 36-411(A) and (C);
Evidence/Findings:
Based on observation, documentation review, record review, and interview, the manager failed to ensure one of three sampled employees or volunteers had a record maintained at the facility.
Findings include:
1. At the time of the abbreviated inspection the compliance officer observed three individuals working at the facility.
2. In an interview, E1 and E2 reported that they were live-in employees. E3 was observed in the facility and stayed in the caregiver room near the front door after the onsite inspection begun. E1 reported that E3 was also a live-in.
3. Review of the employee and volunteer records for the three employees present at the time of this inspection found there was no record for E3.
4. During the interview, E1 acknowledged there was no record for E3, however confirmed that E3 did live at the facility.
Summary:
The following deficiency was found during the on-site abbreviated follow-up inspection conducted on April 18, 2024: