ACTIVE CARE HOMES, LLC

Based on documentation review and interview, the manager failed to review and evaluate the effectiveness of the quality management program at least once every 12 months. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided.

Findings include:

1. In documentation review, the facility's policy, titled "...Quality Management Program...," was not dated. There was no documentation the quality management program was reviewed and evaluated at least once every 12 months.

2. During an interview, E3 acknowledged the facility did not have documentation of a review or evaluation of the effectiveness of the quality management program.

Based on observation and interview, the manager failed to ensure the manager designated, in writing, a caregiver who was present on the facility's premises and accountable for the facility when the manager was not present, as the manager's designee. The deficient practice posed a risk to the residents, if the facility did not have a person designated accountable for the facility when the manager was not present.

Findings include:

1. When the Compliance Officer arrived at the facility, E1, E2 and E5 were present at the facility.

2. During an interview, E1 reported [E1] was designated as accountable for the facility when the manager was not present.

3. In documentation review, a review of a posted written "Delegation of Manager's Authority," did not include E1, E2 or E5.

4. During an interview, E1 acknowledged the documentation was not updated to include the designated caregiver who was present on site and accountable for the facility when the manager was not present.

Based on observation and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver, for one of one assistant caregiver reviewed. The deficient practice posed a risk as the individual was not qualified to provide the required services unsupervised.

Findings include:

1. Arizona Revised Statutes (A.R.S.) \'a7 36-401.A.49. states "Supervision" means "direct overseeing and inspection of the act of accomplishing a function or activity." R9-10-801. Definitions... 2. "Assistant caregiver" means an employee or volunteer who helps a manager or caregiver provide supervisory care services, personal care services, or directed care services to a resident, and does not include a family member.

2. In observation, the Compliance Officer observed E2 feeding R1 in R1's room (unsupervised) during the dinner meal. E2 was observed moving about in different areas of the facility, unsupervised while E1 assisted the Compliance Officer in the survey process, with no other caregiver available to assist the residents.

3. In documentation review, the posted staffing schedule included documentation E2 worked shifts at the facility.

4. During an interview, E1 reported E2 resided at the facility and worked 7am - 7pm daily with Tuesdays off.

5. In record review, E2's personnel record indicated E2 was hired as a "Volunteer," on January 3, 2025. E2's record include documentation of orientation and the verification of skills and knowledge.

6. During an interview, E3 reported E2 worked under the supervision of E1; however, acknowledged E2 was observed providing services to a resident without supervision. E3 acknowledged an assistant caregiver or volunteer was required to interact with residents under the supervision of a manager or caregiver.

Based on observation, interview, and record review, for one of two residents reviewed, the manager failed to ensure a resident had a written service plan which included a description of the resident's medical or health problems, including physical, behavioral, cognitive, or functional conditions or impairments. The deficient practice posed a risk to residents, if the service plan did not include documentation of the resident's condition, and services to be provided for the resident.

Findings include:

1. In observation, R1 was observed in bed during the inspection.

2. During an interview, E1 reported R1 was incontinent and had skin problems, which included a rash, dryness and sometimes bleeding in the groin area. A hospice nurse visited and the nurse and the caregivers provided skin maintenance services for R1.

3. In record review, R1's service plan dated January 23, 2025 (received directed care services) indicated R1 was continent; however required brief changes every 2-3 hours. The service plan did not include documentation of R1's skin problems.

4. During an interview, E1 and E3 acknowledged R1's service plan did not include documentation of the resident's medical or health problems, as required.

Based on record review and interview, for one of two residents reviewed, the manager failed to ensure a written service plan included the signature and date from the resident or resident's representative. The deficient practice posed a health and safety risk if the resident or the resident's representative did not acknowledge the services that were to be provided.

Findings include:

1. In record review, the service plan for R1, dated January 23, 2025, did not include the signature and date from the resident or the resident's representative. R1 received directed care services.

2. During an interview, E1 acknowledged R1's service plan was not signed and dated, by the resident or the resident's representative.

Based on interview and record review, for one resident confined to a bed or chair and unable to ambulate, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a primary care provider (PCP) or medical practitioner (MP), upon acceptance or upon the onset of the condition, and every six months thereafter, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services. The deficient practice posed a safety risk to a resident, if a facility retained a resident without the required authorization.

Findings include:

1. In record review, R1's service plan (received directed care services), dated January 23, 2025, included documention R1 was "bedbound... hemiplegia..." R1's record did not include a written determination from a PCP or MP, that stated the resident's needs could be met by the facility.

2. During an interview, E1 and E3 reported they did not know how long R1 was unable to walk; however, reported R1 was unable to walk even with assistance, and acknowledged a written determination from a PCP or MP was required upon acceptance or upon the onset of the condition, and every six months by the facility.

Based on documentation review, observation, and interview, for a facility that provided directed care services, the manager failed to ensure there was a means of exiting the facility that provided access to an outside area which controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident.

Findings include:

1. A review of the license issued by the Department revealed the facility was licensed at the directed care level.

2. The Compliance Officer observed a patio door to the backyard was open, and did not control or alert employees of the egress of a resident. The door had a working alarm.

3. The Compliance Officer observed the bedrooms for R3, R7 and R8, had an unlocked door to the outside, with an alarm on the door. However, the alarm was turned off.

4. In an interview, E1 and E3 acknowledged the facility was required to ensure there was a means of exiting the facility that provided access to an outside area which was controlled or alerted employees of the egress of a resident from the facility. E1 turned the door alarms on during the inspection.

Based on observation, documentation review, and interview, the manager failed to ensure there was a current toxicology reference guide available for use by personnel members.

Findings include:

1. During an interview, the Compliance Officer requested to review the facility's current toxicology reference guide.

2. In documentation review, no toxicology reference guide was provided for review.

3. During an interview, E3 acknowledged the facility did not have a current toxicology reference guide available for use by personnel members.

Based on observation, record review, and interview, for two of two residents reviewed, who received a controlled substance, the manager failed to ensure policies and procedures were implemented for inventorying controlled substances. The deficient practice posed a risk if controlled substances were not inventoried and accounted for by the facility.

Findings include:

1. In observation, the Compliance Officer observed R1's medications on site, including Morphine medication.

2. In record review, R1's medical record (received directed care services), included a medication order for Morphine (a Schedule II controlled substance) 30mg ER, one tablet po BID. R1's medication administration record (MAR) dated January 2025 and February 2025, included documentation R1 received the Morphine medication twice daily from January 1, 2025 through February 5, 2025. The record did not include an inventory of the controlled substances.

3. In observation, R2's medications were observed on site, including Oxycodone, and Fentanyl Patches.

4. In record review, R2's medical record (received personal care and medication administration services) included a medication order for Oxycodone (a Schedule II controlled substance) HCI Tablet 10mg, take one tablet eery 6 hours, Oxycodone 10mg, take one tablet by mouth QID every 4 hours for pain, Morphine Sulfate (a Schedule II controlled substance) Solution 20mg/1ml, take 0.25 ml under tongue every hour PRN, and Fentanyl dis (a Schedule I controlled substance) 25 mcg/hr. Apply one patch topically on left... q 72 hours. R2's medication administration record dated January 2025 through February 5, 2025, included documentation R2 received the medications, as ordered. R2's record did not include documentation of an inventory of the controlled substances.

5. During an interview, E1 and E3 acknowledged the facility did not maintain an inventory of controlled substances, as required.

Based on observation and interview, the manager failed to ensure toxic materials stored by the facility were stored in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident if toxic materials were accessible.

Findings include:

1. During an environmental inspection with E1, the Compliance Officer observed a cabinet beneath the kitchen sink contained a bottle of bleach and multipurpose cleaner. A can of Ant and Roach spray was observed on a table on the patio outside R3's bedroom. R3's patio door was unlocked and the patio was accessible.

2. During an interview, R3 reported using the Roach and Ant spray to spray the ants located outside.

3. During an interview, E1 acknowledged the toxic materials were not stored in a locked area and inaccessible to residents.

Based on record review, observation, documentation review, and interview, for one of two residents reviewed, who received opioid medication, without an active malignancy or an end of life condition, the manager failed to ensure an individual authorized to administer opioids documented in the resident's medical record; an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered. The deficient practice posed a risk to a resident's health and safety if the facility did not appropriately assess and monitor opioid administration for a resident.

Findings include:

1. In record review, R2's medical record (received personal care and medication administration services) included a medication order for Oxycodone HCI Tablet 10mg, take one tablet every 6 hours, Oxycodone 10mg, take one tablet by mouth QID every 4 hours for pain, Morphine Sulfate Solution 20mg/1ml, take 0.25 ml under tongue every hour PRN, and Fentanyl dis 25 mcg/hr. Apply one patch topically on left... q 72 hours. R2's medication administration record (MAR) dated January 2025 through February 5, 2025, included documentation R2 received the Opioid medication, as prescribed. R2's medical record did not include documentation of an active malignancy or end of life condition, and did not include documentation of an identification of the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered.

2. In observation, R2's medications were observed on site.

3. In documentation review, a facility policy, titled, "Opioid Medications, ...." documented, "... Before administering an opioid.. a trained certified caregiver identifies the resident's need for the opioid... using the "pain Scale" assessment tool... Resident's pain is identified and documented on the medication administration records... Caregivers will monitor the resident's response to any opioid administered..."

4. During an interview, E1 reported the opioid medication was administered to R2 daily, as ordered, and on an as needed basis, as ordered, for pain, and R2 did not have an active malignancy or an end of life condition. E1 and E3 acknowledged the caregivers were not trained on opioid medication administration, and did not document the resident's need for the opioid before the opioid was administered, and the monitoring of the effect of the opioid administered, as required by R9-10-120.F.

Based on record review and interview, the manager failed to ensure a medical record was maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1. The deficient practice posed a risk as required information could not be verified for three residents.

Findings include:

1. A.R.S. Title 12, Chapter 13, Article 7.1 states, "Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: 1. If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider."

2. During the inspection, the Compliance Officer requested to review the medical records of R1, R2, R3, and R4 from E2 and E3. However, E2 and E3 reported that the medical records for R1, R2, and R3 were not available.

3. In a telephonic interview, the Compliance Officer questioned E1 regarding the medical records of R1, R2, and R3. E1 stated that the medical records were available; however, E1 was unable to provide the records at the time of the inspection. E1 acknowledged that the medical records for R1, R2, and R3 were not available for review during the inspection.