Rule/Regulation Violated:
A. A manager shall ensure that:
5. An assisted living facility has a manager, caregivers, and assistant caregivers with the qualifications, experience, skills, and knowledge necessary to:
a. Provide the assisted living services, behavioral health services, behavioral care, and ancillary services in the assisted living facility's scope of services;
b. Meet the needs of a resident; and
c. Ensure the health and safety of a resident;
Evidence/Findings:
Based on observation, record review, documentation review, and interview, the administrator failed to ensure sufficient personnel members were present on a behavioral health residential facility's premises with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident, and ensure the health and safety of a resident. The deficient practice posed a risk as a qualified personnel member was not present to meet a resident's needs and ensure the health and safety of a resident.
Findings include:
1. The Compliance Officer observed E1 and E2 working at the facility upon arrival at 8:20 AM.
2. A review of E2's (hired in 2021) personnel record revealed E2 was hired as a caregiver. The record revealed a caregiver certificate (dated May 15, 2012) from "Platinum Training Services LLC...ALTP0185."
3. A review of https://nciaboard.az.gov/news/caregiver-certificate-verification website revealed the caregiver training program "ALTP #185" was valid from July 16, 2012 through August 2, 2013.
4. A review of https://nciaboard.az.gov/news/fraudulent-caregiver-certificates revealed E2 had not completed a caregiver training program.
5. In an interview, E2 reported E2 completed caregiver training at an assisted living facility E2 worked at previously.
6. In a joint interview, E3 and E4 acknowledged the assisted living facility did not have a caregiver with the qualifications, experience, skills, and knowledge necessary to meet the needs of a resident and ensure the health and safety.
Summary:
No deficiencies were found during the on-site compliance inspection conducted on January 9, 2025.