Rule/Regulation Violated:
B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and:
1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services:
a. Includes whether the individual requires:
i. Continuous medical services,
ii. Continuous or intermittent nursing services, or
iii. Restraints; and
b. Is dated and signed by a:
i. Physician,
ii. Registered nurse practitioner,
iii. Registered nurse, or
iv. Physician assistant; and
2. If an individual is requesting or is expected to receive behavioral health services, other than behavioral care, in addition to supervisory care services, personal care services, or directed care services from an assisted living facility:
a. Includes whether the individual requires continuous behavioral health services, and
b. Is signed and dated by a behavioral health professional.
Evidence/Findings:
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 by the assisted living facility to indicate whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints, for one of four sampled residents. The deficient practice posed a risk if the facility was unable to meet a resident's needs.
Findings include:
1. A review of R2's medical record revealed documentation stating whether R2 required continuous medical services, continuous or intermittent nursing services, or restraints was not available for review at the time of inspection.
2. In an interview, E1 acknowledged R2 had no documentation showing if R2 needed continuous medical services, nursing services, or restraints.
Summary:
The following deficiencies were found during the on-site compliance inspection conducted on February 4, 2025: