BEST OF EUROPE ADULT HOME CARE LLC

<p>Based on documentation review and interview, the manager failed to ensure policies and procedures were established, documented, and implemented, which covered required skills and knowledge.</p><p><br></p><p><br></p><p><br></p><p>Findings include:</p><p><br></p><p><br></p><p><br></p><p>1 . A review of facility documentation revealed a policy that covered required skills and knowledge verified and documented by the facility was not available for review at the time of inspection.</p><p><br></p><p><br></p><p><br></p><p>2 . In an interview, E1 acknowledged a policy for skills and knowledge verification was not available for review.</p>

<p>Based on record review and interview, the manager failed to ensure a caregiver's or assistant caregiver's skills and knowledge were verified and documented b<span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">efore the caregiver or assistant caregiver provided physical health services or behavioral health services for two of two caregivers sampled. </span><span style="font-size: 14.625px;">The deficient practice posed a risk if the employees were unable to meet a resident's needs.</span></p><p><br></p><p><br></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">Findings include:</span></p><p><br></p><p><br></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">1 . A review of E2's and E3's personnel records revealed documentation of skills and knowledge verification was not available for review at the time of inspection. </span></p><p><br></p><p><br></p><p><br></p><p><span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">2 . In an interview, E1 acknowledged E2's and E3's personnel records had not contained documentation of skills and knowledge verification at the time of inspection. </span></p>

<p>Based on documentation review, observation, and interview, the manager failed to ensure t<span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">here was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort which provided access to an outside area which monitored or alerted employees of the egress of a resident from the facility.</span></p><p><br></p><p><br></p><p><br></p><p>1 . A review of facility documentation revealed the facility was licensed to provide directed care.</p><p><br></p><p><br></p><p><br></p><p>2 . During an environmental inspection of the facility, the Compliance Officers observed a door leading from the kitchen to the backyard and another door on the side of the house, also leading to the backyard. The doors had no alerts, and no monitoring system in place.</p><p><br></p><p><br></p><p><br></p><p>3 . <span style="color: rgb(68, 68, 68); background-color: rgb(255, 255, 255);">During an environmental inspection of the facility, the Compliance Officers observed a door leading from the back of the facility to the backyard. The door had an alert. However, the alert was not functioning at the time of inspection. </span></p><p><br></p><p><br></p><p><br></p><p>4 . In an interview, E1 acknowledged the doors in the facility had no alert or monitoring system, and E1 reported the alerts would be replaced the same day.</p>

Based on 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. Review of the record for E2 (hired March 25, 2023), revealed no documentation of fall prevention and fall recovery training.
2. During an interview, E1 acknowledged that training for fall prevention and fall recovery had not been administered to all staff.

Based on record review and interview, the manager failed to ensure that for three of three sample resident records, a standardized emergency responder patient information form as described in subsection A. of this section, was completed and maintained for each resident.

Findings include:
1. The medical record for R1 did not contain the completed emergency responder patient information documentation.
2. The medical record for R2 did not contain the completed emergency responder patient information documentation.
3. The medical record for R3 did not contain the completed emergency responder patient information documentation.
4. During an interview, E1 acknowledged that the required documentation was not available for review.

Based on record review and interview, the chief administrative officer failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annual training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution.

Findings include:
1. Review of the record for E2 failed to reveal documentation indicating that annual training related to recognizing the signs and symptoms of TB had been completed. No TB training documentation was available for review.
2. During an interview, E1 acknowledge that the required documentation was not available.

Based on record review and interview, the governing authority failed to ensure that one of three sample personnel records included documentation that a copy of the employee's current fingerprint clearance card had been obtained and verified with the Department of Public Safety.

Findings include:
1. The record for E2 (start date August 9, 2022) contained a Department of Public Safety (DPS) fingerprint clearance card that expired on February 13, 2023. No additional documentation was present in the record reflecting that DPS was contacted to renew the fingerprint clearance card.
2. During an interview, E1 acknowledged the required documentation was not in the records.
3. Review of the DPS web site revealed that the card was expired.

Based on record review and interview, the manager failed to ensure that one of one sample records for a volunteer included the starting date of volunteer service.

Findings include:
1. The record for volunteer O1 did not contain the volunteer's starting date of service.
2. During an interview, E1 acknowledged the record for the volunteer did not include the starting date of service.

Based on record review and interview, the manager failed to ensure that three of three sample resident records contained documentation of notification to the resident of the availability of a vaccination for pneumonia.

Findings include:
1. The record belonging to R1 contained documentation indicating that the resident was last notified of the availability of the pneumonia vaccination on December 1, 2020. No additional documentation indicating when the resident had been offered, refused or received either vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required.
2. The record belonging to R2 contained documentation indicating that the resident was last notified of the availability of the pneumonia vaccination on March 13, 2018. No additional documentation indicating when the resident had been offered, refused or received either vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required.
3. The record belonging to R3 contained no documentation indicating that the resident was notified of the availability of the pneumonia vaccination. No additional documentation indicating when the resident had been offered, refused or received either vaccination, was available for review. Based on the resident's date of acceptance, this documentation was required.
4. During an interview, E1 acknowledged that the vaccination had been made available to the residents on a yearly basis however the record did not contain the required documentation.

Based on record review and interview for one of one sample directed care resident record, the manager failed to obtain a signed and dated statement from a medical practitioner at least once every six months, indicating that the resident's needs were being met by the facility as per their scope of services.

Findings include:
1. During an interview, E1 indicated that R1 was non-ambulatory, has not walked for more than 30 days and cannot walk even when assisted.
2. The last determination of residency signed by a medical practitioner indicating that the resident's needs were being met as per the facility's scope of services, was dated December 14, 2020. Based on the resident's date of acceptance this documentation was required.
3. During an interview, E1 acknowledged that documentation from the medical practitioner was not in the record at least once every six months throughout the duration of the resident's condition.

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented.

Findings include:
1. Facility documentation failed to reflect that disaster drills had been conducted within the past 12 months.
2. During an interview, E1 stated, "We have three shifts, we haven't been running disaster drills."
3. During an interview, E1 acknowledged that no documentation of employee disaster drills was available for review.

Based on documentation review and interview, the manager failed to ensure that one of one pet that is allowed in the facility, was licensed consistent with local ordinances.

Findings include:
1. Documentation for a dog (O2) allowed in the facility failed to reflect that the dog was licensed.
2. During a telephone interview with the local authority it was determined that the dog required a license.
3. During an interview, E1 acknowledged that facility documentation failed to indicate the dog had a current license.