AN ENCHANTED ASSISTED LIVING LLC

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for three of three employees. The deficient practice posed a risk if the employee was a danger to a vulnerable population.

Findings include:

1. A.R.S. \'a7 36-411 states, "A... as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work... C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency. 2. Verify the current status of a person's fingerprint clearance card..."

2. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of May 1, 2023. The personnel record revealed a fingerprint card issued on June 11, 2021. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E1's fitness to work in a residential care institution.

3. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of May 1, 2023. The personnel record revealed a fingerprint card issued on July 15, 2022. However, the personnel record did not contain documentation of good faith efforts to contact previous employers to obtain information or recommendations that may be relevant to E2's fitness to work in a residential care institution.

4. Review of E3's personnel record revealed E3 worked as a caregiver and had a hire date of May 1, 2023. The personnel record revealed a fingerprint card issued April 7, 2023. However, the record did not contain documentation showing the card was verified with the Department of Public Safety (DPS) .

5. Review of the DPS fingerprint clearance card database on August 11, 2023, revealed E1's, E2's, and E3's fingerprint clearance cards were valid.

6. In an interview, E1 acknowledged documentation was not available showing E1's and E2's work references were obtained and E3's fingerprint card was verified with DPS upon hire.

Based on record review, documentation review, and interview, the manager failed to ensure a caregiver received orientation that was specific to the duties to be performed before providing assisted living services to a resident, for two of three caregivers. The deficient practice posed a risk if the employees were unable to meet resident's needs.

Findings include:

1. Review of E1's personnel record revealed E1 worked as the manager and had a hire date of May 1, 2023. The personnel record revealed no documentation showing E1 had received orientation specific to the duties to be performed.

2. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of May 1, 2023. The personnel record revealed no documentation showing E2 had received orientation specific to the duties to be performed.

3. Review of the facility's policy and procedure revealed a policy titled "Orientation and In-Service Training" that stated "New employee orientation is required to be completed by all new employees and volunteers before starting to provide assisted living services to the residents ..."

4. In an interview, E1 acknowledged documentation was not available showing E1 and E2 received orientation specific to the duties to be performed.

Based on record review, observation, and interview, the manager failed to ensure a medication administered to a resident was documented in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as medication could not be verified as administered against a medication order.

Findings include:

1. Review of R1's medical record revealed a current written service plan dated July 21, 2023. This service plan indicated R1 received medication administration.

2. Review of R1's medical record revealed a signed medication order dated August 9, 2023. This medication order stated "Senna Plus 8.6mg/50mg PO two times daily PRN".

3. Review of R1's medical record revealed an August 2023 medication administration record (MAR). This MAR stated "Senna Plus 8.6mg/50mg PO two tabs daily as needed" however did not indicate Senna Plus was administered August 1st - present.

4. During an observation of R1's medications, Senna Plus 8.6mg/50mg was observed and one tab was observed prefilled in the "Morn" slot of R1's medication organizer.

5. In an interview, E1 reported one tab of Senna Plus was currently administered daily and acknowledged R1's medical record did not include documentation the medication was administered.

Based on observation and interview, the manager failed to ensure medications stored by the facility were stored in a separate locked room, closet, cabinet, or self-contained unit. The deficient practice posed a risk to residents who could access the medication.

Findings include:

1. During an environmental inspection of the facility with E1, the Compliance Officer observed Lantus, Lorazepam, and ABH 1/25/1 gel unlocked in a box in the kitchen refrigerator. This box had a locking device, however the device was not locked.

2. During an observation, E1 was the only employee at the facility when the Compliance Officer arrived and was not accessing the medications at the time of arrival.

3. In an interview, E1 acknowledged medications were stored unlocked.