AMERICAN CARE HOMES, INC

INSP-0130548

SOD

Date: 5/8/2025

Type: Compliance (Annual)

Worksheet: Behavioral Health Residential Facility

SOD Sent: 2025-06-12

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on May 8, 2025.

Deficiencies Found: 10

Deficiency #1

Rule/Regulation Violated:

R9-10-113.A.2.a-f. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on record review, documentation review, and interview, the administrator failed to implement tuberculosis (TB) infection control activities which included baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB, for five of seven personnel records sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: R9-10-113.B.1.c.(i-ii) B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. ii. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R96-101; and Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution. 1. A review of E2's personnel record revealed one negative Mantoux skin test. However, there was no documentation of a second negative TB screening test or baseline screening assessing risks of prior exposure to infectious TB available for review. 2. A review of E3's personnel record revealed one negative Mantoux skin test. However, there was no documentation of a second negative TB screening test or baseline screening assessing risks of prior exposure to infectious TB available for review. 3. A review of E5's personnel record revealed two negative Mantoux skin tests. However, there was no documentation of a baseline screening assessing risks of prior exposure to infectious TB available for review. 4. A review of the facility's policies and procedures revealed a policy titled "Staffing Requirements/Qualifications" (no date). The procedure stated, "Prior to working with residents: All staff members, volunteers and interns will submit evidence of freedom from infectious pulmonary tuberculosis as a negative Mantoux skin test or a written statement from a medical practitioner." 5. In an exit interview, E1, E5, and E7 reviewed the findings and no additional documentation was provided. This is a repeated deficiency from the on-site compliance inspection conducted on May 28, 2024.

Deficiency #2

Rule/Regulation Violated:

R9-10-707.A.13.b. Admission; Assessment A. An administrator shall ensure that: 13. Except as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis: b. As specified in R9-10-113.

Evidence/Findings:

Based on record review, documentation review, and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the residents admission, and as specified in R9-10-113, for two of three resident records sampled. The deficient practice posed a TB exposure risk. Findings include: 1. A review of R2's medical record revealed no documentation of a screening for signs and symptoms of TB available for review. 2. A review of R3's medical record revealed no documentation of a negative TB test or screening for signs and symptoms of TB available for review. 3. A review of facility documentation revealed a policy and procedure titled "Tuberculosis Screening." The policy stated, "... Records: a) Documentation of the tuberculosis screening test of an individual admitted to the facility will be maintained at the facility in the resident file; b) Documentation of screening for signs and symptoms of tuberculosis of an individual admitted to the facility will be maintained at the facility in the resident file..." 4. In an exit interview, E1, E5, and E7 reviewed the findings and no additional documentation was provided. This is a repeated deficiency from the on-site compliance inspection conducted on May 28, 2024.

Deficiency #3

Rule/Regulation Violated:

R9-10-712.C.15. Medical Records C. An administrator shall ensure that a resident's medical record contains: 15. Documentation of behavioral health services and physical health services provided to the resident;

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure a resident's medical record contained documentation of behavioral health services provided to a resident, for three of three resident records sampled. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution. Findings include: R9-10-716.B.2. B. An administrator shall ensure that counseling is: 2. Provided according to the frequency and number of hours identified in the resident's treatment plan. 1. A review of R1's medical record revealed a treatment plan dated in 2025. The treatment plan stated, "Attend therapy sessions as scheduled or recommended by the BHP." However, the treatment plan did not specify the frequency and number of hours for counseling to be provided. 2. A review of R2's medical record revealed a treatment plan dated in 2025. The treatment plan stated, "1-1 therapy 1-1 as scheduled..." However, the treatment plan did not specify the frequency and number of hours for counseling to be provided. 3. A review of R3's medical record revealed a treatment plan dated in 2025. The treatment plan stated, "1-1 therapy 1-1 as scheduled..." However, the treatment plan did not specify the frequency and number of hours for counseling to be provided. 4. In an exit interview, E1, E5, and E7 reviewed the findings and no additional documentation was provided. This is a repeated deficiency from the on-site compliance inspection conducted on May 28, 2024.

Deficiency #4

Rule/Regulation Violated:

R9-10-721.A.14. Environmental Standards A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 14. Poisonous or toxic materials stored by the behavioral health residential facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

Evidence/Findings:

Based on observation and interview, the administrator failed to ensure poisonous or toxic materials stored by the behavioral health residential facility were maintained in a locked area and were inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. The Compliance Officer observed a 7.5 ounce aerosol can of "Homebright Disinfectant Spray" and a 19 ounce aerosol can of" Lysol Disinfectant Spray" located in the bathroom in R1's and another resident's bedroom. 2. The Compliance Officer observed four five-gallon buckets of paint located in the unlocked shed in the backyard of the facility. 3. In an exit interview, E1, E5, and E7 reviewed the findings and no additional documentation was provided. This is a repeated deficiency from the on-site compliance inspection conducted on May 28, 2024.

Deficiency #5

Rule/Regulation Violated:

R9-10-113.A.1-2. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 1. Are consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments; and 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupation health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101; c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis; e. Reporting, as specified in A.A.C. R9-6-202, an individual who is suspected of exposure to infectious tuberculosis; and f. If an exposure to infectious tuberculosis occurs in the health care institution, coordinating and sharing information with the local health agency, as defined in A.A.C. R9-6-101, for identifying, locating, and investigating contacts, as defined in A.A.C. R9-6-101.

Evidence/Findings:

Based on record review, documentation review, and interview, the administrator failed to ensure annual training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution was provided, for four of seven personnel records sampled. The deficient practice posed a risk as a process reinforces and clarifies standards expected of employees. Findings include: 1. A review of E3's, E4's, E5's, and E7's personnel records revealed no annual training and education related to recognizing the signs and symptoms of TB was available for review. 2. In an exit interview, E1, E5, and E7 reviewing the findings and no additional documentation was provided.

Deficiency #6

Rule/Regulation Violated:

R9-10-703.C.5.a-b. Administration C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and b. When documentation or information is required by this Chapter to be submitted on behalf of a behavioral health residential facility, the documentation or information is provided to the unit in the Department that is responsible for licensing and monitoring the behavioral health residential facility.

Evidence/Findings:

Based on record review, documentation review, and interview, the administrator failed to ensure documentation required by Article 7 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. The Compliance Officer requested the following at 09:00 AM:-Emergency and safety standard documentation (disaster drills, evacuation drills, maintenance logs, current fire inspection report, etc.);-Policies and procedures and scope of services;-Quality management program and corresponding documentation;-Incident reports from the last 12 months (if applicable);-Employee staffing schedules from the last 12 months; -Food services contract/service agreement with a registered dietitian with food menus;-Personnel records (complete with all required documents) for E1, E2, E3, E4, E5, E6, and E7; and-Resident medical records (complete with all required documents) for R1, R2, and R3. 2. The following documentation was not provided to the Compliance Officers for review by 11:00 AM:-Documentation of disaster drills for employees on each shift for June 14, 2024, September 14, 2024, December 14, 2024, and March 14, 2025;-Policies and procedures and scope of services;-Signatures of personnel members who attended clinical oversight meetings with the facility's BHP on June 24, 2024 and October 23, 2024;-Documentation of updated, completed training in assistance in the self-administration of medication for E5 and E7;-Documentation of continued competency training and fall prevention and fall recovery for E2, E3, E4, and E6; and-Documentation of current training and education related to recognizing the signs and symptoms of tuberculosis. 3. In an interview, the Compliance Officer requested the facility's policies and procedures and scope of services from E3 at approximately 09:10 AM. E3 reported the requested documentation was not available for review. When E1 arrived at the facility, E1 reported E1 would electronically provide the policies and procedures and scope of services to the Compliance Officer during the on-site compliance inspection. The requested documentation was not provided by E1 by the end of the inspection. The Compliance Officer sent electronic notification on May 9, 2025 at 10:21 AM requesting the facility's policies and procedures. However, the requested documentation was not provided. 4. In an exit interview, E1, E5, and E7 reviewed the findings and no additional documentation was provided.

Deficiency #7

Rule/Regulation Violated:

R9-10-705.1-2. Contracted Services An administrator shall ensure that: 1. Contracted services are provided according to the requirements in this Article, and 2. Documentation of current contracted services is maintained that includes a description of the contracted services provided.

Evidence/Findings:

Based on record review, documentation review, and interview, the administrator failed to ensure documentation of current contracted services was maintained which included a description of the contracted services provided, for two of three contracted personnel records sampled. The deficient practice posed a risk as the Department was unable to verify services were provided to residents as documented and required in A.A.C. R9-10-706.K.4-5. Findings include: 1. A review of E2's personnel record revealed E2 was contracted and hired as a behavioral health professional for the facility. 2. A review of E2's personnel record revealed a contract. However, there was no documentation in the contract which stated E2 needed to be present at the behavioral health residential facility or on-call. 3. A review of E3's personnel record revealed E3 was contracted and hired as a registered nurse for the facility. 4. A review of E3's personnel record revealed a contract. However, there was no documentation in the contract which stated E3 needed to be present at the behavioral health residential facility or on-call. 5. In an exit interview, E1, E5, and E7 reviewed the findings and no additional documentation was provided.

Deficiency #8

Rule/Regulation Violated:

R9-10-708.A.4.c. Treatment Plan A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that: 4. Includes: c. The signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign;

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure a treatment plan was developed and implemented for each resident which included the signature of the resident or the resident's representative, and date signed, or documentation of the refusal to sign, for two of three resident records sampled. The deficient practice posed a risk as a treatment plan was not completed to articulate decisions and agreements of services to be provided. Findings include: 1. A review of R1's medical record revealed a treatment plan dated in 2025. However, the treatment plan did not include the signature of the resident, and date signed, or documentation of the refusal to sign. 2. A review of R2's medical record revealed a treatment plan dated in 2025. However, the treatment plan did not include the signature of the resident, and date signed, or documentation of the refusal to sign. 3. In an exit interview, E1, E5, and E7 reviewed the findings and no additional documentation was provided.

Deficiency #9

Rule/Regulation Violated:

R9-10-716.C.2.e. Behavioral Health Services C. An administrator shall ensure that: 2. Each counseling session is documented in a resident's medical record to include: e. The signature of the personnel member who provided the counseling and the date signed.

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure each counseling session was documented in a resident's medical record to include the signature of a personnel member who provided counseling and the date signed, for one of three resident records sampled. The deficient practice posed a risk as the Department was unable to verify services were provided to the resident. Findings include: 1. A review of R1's medical record revealed an individual counseling note for 30 minutes which contained E6's printed name at the bottom. However, the signature section for a personnel member who provided the counseling and the date signed section were left blank. 2. In an exit interview, E1, E5, and E7 reviewed the findings and no additional documentation was provided.

Deficiency #10

Rule/Regulation Violated:

R9-10-720.B.4. Emergency and Safety Standards B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;

Evidence/Findings:

Based on documentation review and interview, the administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed disaster drills conducted on March 14, 2025 at 10:00 AM, December 14, 2024 at 01:00 PM, September 14, 2024 at 01:00 PM, June 14, 2024 at 01:00 PM, and March 14, 2024 at 07:30 PM. However, no documentation of the disaster drills for employees conducted on other shifts was available for review. 2. In an interview, E7 reported to E1 the disaster drills not being conducted by employees on each shift was communicated prior to the exit interview of the inspection. 3. In an exit interview, E1, E5, and E7 reviewed the findings and no additional documentation or statements were provided.

INSP-0058730

Complete

Date: 5/28/2024

Type: Compliance (Annual)

Worksheet: Behavioral Health Residential Facility

SOD Sent: 2024-06-25

Summary:

The following deficiencies were found during the on-site compliance inspection conducted on May 28, 2024:

Deficiencies Found: 18

Deficiency #1

Rule/Regulation Violated:

36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition
A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.

Evidence/Findings:

Based on documentation review, record review, and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, " 67.0 Fall Prevention and Fall Recovery Training." However, the policy did not include a continued competency component.

2. A review of E6's personnel record revealed a fall prevention and fall recovery training dated August 16, 2022. However, documentation of a continued competency training in fall prevention and fall recovery was not available for review.

3. A review of E7's personnel record revealed a slips, trips, and falls training from Arizona Provider's Training dated May 12, 2022. However, documentation of an initial training in fall recovery and continued competency training was not available for review.

4. In an interview, E1 acknowledged an initial and continued competency training in fall prevention and fall recovery was not administered and documented.

Deficiency #2

Rule/Regulation Violated:

M. An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are available upon request to a personnel member, employee, resident, or a resident's representative:
2. The location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review, and

Evidence/Findings:

Based on observation and interview, the administrator failed to ensure the location at which inspection reports required in R9-10-720(C) are available for review or can be made available for review was conspicuously posted on the premises.

Findings include:

1. The Compliance Officer observed several facility postings, however, a posting for inspection reports was not available for review.

2. In an interview, E1 acknowledged the required posting was not conspicuously posted on the premises.

Deficiency #3

Rule/Regulation Violated:

M. An administrator shall ensure that the following information or documents are conspicuously posted on the premises and are available upon request to a personnel member, employee, resident, or a resident's representative:
3. The calendar days and times when a resident may accept visitors or make telephone calls.

Evidence/Findings:

Based on observation and interview, the administrator failed to ensure the calendar days and times when a resident may accept visitors or make telephone calls was conspicuously posted on the premises.

Findings include:

1. The Compliance Officer observed several facility postings, however, a posting for the calendar days and times when a resident may accept visitors or make telephone calls was not available for review.

2. In an interview, E1 acknowledged the required posting was not conspicuously posted on the premises.

Deficiency #4

Rule/Regulation Violated:

G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:
3. Documentation of:
c. The individual's completed orientation and in-service education as required by policies and procedures;

Evidence/Findings:

Based on documentation review, record review, and interview, the administrator failed to ensure documentation of an individual's completed orientation was maintained in a personnel record, for one of seven personnel members sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, " 6.0 Orientation and Training." The policy stated, "... All staff members will complete orientation and training before providing behavioral health services... 2. The staff member's orientation will be documented to include: the staff members name, signature, and professional credential or job title; the date orientation was completed; the subject or topics covered in the orientation; the duration of the orientation; the name, signature, and professional credential or job title of the individual providing the orientation..."

2. A review of E5's personnel record revealed documentation of the individuals completed orientation was not available for review.

3. In an interview, E1 acknowledged documentation of E5's completed orientation was not available for review.

Deficiency #5

Rule/Regulation Violated:

G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:
3. Documentation of:
d. The individual's license or certification, if the individual is required to be licensed or certified in this Article or policies and procedures;

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure documentation of an individuals license or certification was maintained in a personnel record.

Findings include:

1. A review of E4's personnel record revealed an expired registered dietician license.

2. In an interview, E1 reported E4's license was valid but E1 has not updated the documents in E4's personnel record.

Deficiency #6

Rule/Regulation Violated:

G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:
3. Documentation of:
e. The individual's compliance with requirements in A.R.S. §§ 36-411, 36-411.01, and 36-425.03, as applicable;

Evidence/Findings:

Based on documentation review, record review, and interview, the administrator failed to ensure documentation of an individual's compliance with requirements in A.R.S. \'a7 36-411 was maintained in a personnel record. The deficient practice posed a health and safety risk to residents if E1, E2, E3, E3, or E7 were a danger to a vulnerable population.

Findings include:

A.R.S. \'a7 36-411(C)(1) Owners shall make documented, good faith efforts to 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.

1. A review of facility documentation revealed a policy and procedure titled, " 7.0 Employee Personnel Records." The policy stated, "... 3. Personnel records will include documentation indicating the staff member is in compliance with the following: fingerprint clearance card, verified documentation that fingerprint clearance has been verified and is valid and in good standing with DPS..."

2. A review of E1's personnel record revealed an expired fingerprint clearance card dated April 11, 2017 to April 11, 2023. However, documentation of a current fingerprint clearance card was not available for review.

3. A review of E1's, E2's, E3's, E5's, and E7's personnel record revealed documentation in compliance with A.R.S. \'a7 36-411(C)(1) was not provided for review.

4. In an interview, E1 reported E1 had applied for an updated fingerprint clearance card but had not received it yet.

5. In an interview, E1 acknowledged documentation in compliance with A.R.S. \'a7 36-411(C)(1) documented and maintained in the personnel records.

Deficiency #7

Rule/Regulation Violated:

G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:
3. Documentation of:
h. Cardiopulmonary resuscitation training, if required for the individual according to R9-10-703(C)(1)(e);

Evidence/Findings:

Based on facility documentation, record review, and interview, the administrator failed to ensure documentation of cardiopulmonary resuscitation (CPR) training was maintained in a personnel record. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, " 7.0 Employee Personnel Records." The policy stated, "... 3. Personnel records will include documentation indicating the staff member is in compliance with the following: fingerprint clearance card, verified documentation that fingerprint clearance has been verified and is valid and in good standing with DPS; CPR and first-aid completion; freedom from infectious pulmonary tuberculosis..."

2. A review of E1's personnel record revealed an expired CPR training certificate dated February 4, 2022 to February 4, 2024. However, documentation of current CPR training was not available for review.

3. A review of E6's personnel record revealed an expired CPR training certificate dated February 4, 2022 to February 4, 2024. However, documentation of current CPR training was not available for review.

4. In an interview, E1 reported the CPR training has been updated but documentation was not in the personnel record.

Deficiency #8

Rule/Regulation Violated:

G. An administrator shall ensure that a personnel record is maintained for each personnel member, employee, volunteer, or student that includes:
3. Documentation of:
i. First aid training, if required for the individual according to this Article or policies and procedures; and

Evidence/Findings:

Based on facility documentation, record review, and interview, the administrator failed to ensure documentation of first-aid training was maintained in a personnel record. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, " 7.0 Employee Personnel Records." The policy stated, "... 3. Personnel records will include documentation indicating the staff member is in compliance with the following: fingerprint clearance card, verified documentation that fingerprint clearance has been verified and is valid and in good standing with DPS; CPR and first-aid completion; freedom from infectious pulmonary tuberculosis..."

2. A review of E1's personnel record revealed an expired first-aid training certificate dated February 4, 2022 to February 4, 2024. However, documentation of current first-aid training was not available for review.

3. A review of E6's personnel record revealed an expired first-aid training certificate dated February 4, 2022 to February 4, 2024. However, documentation of current first-aid training was not available for review.

4. In an interview, E1 reported the first-aid training has been updated but documentation was not in the personnel record.

Deficiency #9

Rule/Regulation Violated:

K. An administrator shall ensure that:
3. There is a daily staffing schedule that:
a. Indicates the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members;

Evidence/Findings:

Based on observation and interview, the administrator failed to ensure the daily staffing schedule indicated the date, scheduled work hours, and name of each employee assigned to work, including on-call personnel members.

Findings include:

1. The Compliance Officer observed a staffing schedule posted at the entrance of the facility titled, " H1 April 2024." The schedule revealed a behavioral health professional and behavioral health technician on-call, however, no registered nurse was listed as on-call.

2. In an interview, E1 acknowledged the posted staffing schedule was not current and a registered nurse was not listed as on-call.

Deficiency #10

Rule/Regulation Violated:

A. An administrator shall ensure that:
6. Except as provided in subsection (E)(1)(a), a medical practitioner performs a medical history and physical examination or a registered nurse performs a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission;

Evidence/Findings:

Based on documentation review, record review, and interview, the administrator failed to ensure a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment on a resident within 30 calendar days before admission or within 72 hours after admission and documents the medical history and physical examination or nursing assessment in the resident's medical record within 72 hours after admission for one of two residents sampled. The deficient practice posed a risk of not meeting a resident's needs if no medical history and physical examination or nursing assessment were completed to assess a resident's needs prior to treatment.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, " 16.0 Assessments/Assessment." The policy stated, "... 2. An assessment completed within twelve (12) months before residents admission date may be used if it is reviewed by a behavioral health professional. All information indicated in this policy must be obtained. Any changes to the condition of the resident must be updated; 3. A behavioral health professional or a behavioral health technician with the oversight and signature of a behavioral health professional will initiate and complete all assessments prior to any treatment and within 24 hours. Assessments will not be conducted by unqualified persons, such as a behavioral health paraprofessional..."

2. A review of R2's (admitted May 2024) medical record revealed no documentation of a nursing assessment or a medical history and physical examination.

3. In an interview, E2 acknowledged R2's medical record revealed no evidence of documentation that a medical practitioner performed a medical history and physical examination or a registered nurse performed a nursing assessment within 30 calendar days before admission or within 72 hours after admission and was documented within 72 hours in R2's medical record.

Deficiency #11

Rule/Regulation Violated:

A. An administrator shall ensure that:
13. Except as provided in subsection (E)(1)(d), a resident provides evidence of freedom from infectious tuberculosis:
a. Before or within seven calendar days after the resident's admission, and
b. As specified in R9-10-113.

Evidence/Findings:

Based on documentation review, record review, and interview, the administrator failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the residents admission, and as specified in R9-10-113. The deficient practice posed a TB exposure risk to residents and staff.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, " Tuberculosis Screening." The policy stated, "... Records: a) Documentation of the tuberculosis screening test of an individual admitted to the facility will be maintained at the facility in the resident file; b) Documentation of screening for signs and symptoms of tuberculosis of an individual admitted to the facility will be maintained at the facility in the resident file..."

2. A review of R2's medical record revealed documentation of a negative TB test and screening for signs and symptoms of TB was not available for review.

3. In an interview, E2 acknowledged R2 did not provide evidence of freedom from infectious TB as specified in R9-10-113.

Deficiency #12

Rule/Regulation Violated:

A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:
2. Is completed:
b. Before the resident receives physical health services or behavioral health services or within 48 hours after the assessment is completed;

Evidence/Findings:

Based on documentation review, record review, and interview, the administrator failed to ensure a treatment plan was developed before the resident received physical health services or behavioral health services. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements before treatment was initiated.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, " 17.0 Treatment Plan." The policy stated, "... 1. The administrator will convene a meeting of the resident, residents case manager or legal guardian and BHP to develop a treatment plan. The treatment plan is developed for each resident that: a. According to the assessment and on-going change on the assessment of the resident the agency will ensure that the following staff will complete the treatment plan b. A registered nurse or a direct care professional under the clinical oversight of the registered nurse will make sure the resident receives physical health services or behavioral health services within 48 hours after the assessment is completed..."

2. A review of R2's medical record revealed a medication administration record (MAR) dated May 2024. The MAR revealed:
- Hdroxyz Pam, 50mg, take 1 capsule Q6, PO, PRN: administered May 6- May 9, May 13- May 16, and May 25- May 26, 2024;
- Methocarbamol, 750mg, take 1 tablet Q6, PO, PRN: administered May 6- May 9, May 11- May 16, and May 25- May 26, 2024;
- Gabapentin, 300mg, take 1 capsule TID, PO: administered May 6- May 9 and May 11- May 16, 2024;
- Clonidine, 0.1mg, Take 1 tablet Q6, PO, PRN (Give for SBP>150 or DBP>100, Do not give if pulse

Deficiency #13

Rule/Regulation Violated:

A. An administrator shall ensure that a treatment plan is developed and implemented for each resident that:
5. If the treatment plan was completed by a behavioral health technician, is reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan to ensure that the treatment plan is complete and accurate and meets the resident's treatment needs; and

Evidence/Findings:

Based on documentation review, record review, and interview, the administrator failed to ensure a treatment plan completed by a behavioral health technician was reviewed and signed by a behavioral health professional within 24 hours after the completion of the treatment plan. The deficient practice posed a risk as a treatment plan was not developed to articulate decisions and agreements before treatment was initiated.

Findings include:

1. A review of facility documentation revealed a policy and procedure titled, "Treatment Plan." The policy stated, "... 5. All treatment plans completed by a behavioral health technician, is reviewed and signed by the registered nurse within 24 hours after the completion of the treatment plan to ensure that the treatment plan is complete and accurate and meets the residents treatment needs on this continuous basis..."

2. A review of R1's medical record revealed treatment plans dated November 8, 2023 and February 8, 2024. However, a signature from the behavioral health professional within 24 hours after the completion of the treatment plans was not available.

3. In an interview, E1 acknowledged the treatment plan was not reviewed and signed by the behavioral health professional.

Deficiency #14

Rule/Regulation Violated:

C. An administrator shall ensure that a resident's medical record contains:
15. Documentation of behavioral health services and physical health services provided to the resident;

Evidence/Findings:

Based on record review and interview, the administrator failed to ensure a residents medical record contained documentation of behavioral health services provided to a resident. The deficient practice posed a risk if a resident did not receive treatment to cure, improve, or palliate their behavioral health issue at the health care institution.

Findings include:

1. A review of R1's medical record revealed a treatment plan dated February 8, 2024. The treatment plan stated, "... attend and actively participate in recovery-based and support group 3x a week... 1:1 therapy 1x a week..."

2. A review of R1's medical record revealed no documentation of counseling provided by the behavioral health facility available for review.

3. In an interview, E1 requested the documentation several times but was not provided with documentation of counseling sessions.

4. In an interview, E1 acknowledged documentation of each counseling session was not in a residents medical record.

Deficiency #15

Rule/Regulation Violated:

B. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, a registered dietitian or director of food services shall ensure that:
3. Meals and snacks provided by the behavioral health residential facility are served according to posted menus;

Evidence/Findings:

Based on documentation review, observation, and interview, the administrator failed to ensure meals and snacks provided by the behavioral health residential facility were served according to posted menus. The deficient practice posed a risk if residents were not meeting their required dietary needs or restrictions.

Findings include:

1. A review of facility documentation revealed a food menu titled, " Weekly Menu Plan." The menu stated, "... 28-May... Lunch: Baked chicken mashed potato w/ gravy... Dinner: Grilled cheese sandwich french fries..."

2. The Compliance Officer observed a resident ask R2 what R2 was having for lunch. R2 replied, "I'm making spaghetti."

3. The Compliance Officer observed R2 cooking spaghetti.

4. In an interview, E1 acknowledged meals were not provided according to posted food menus.

Deficiency #16

Rule/Regulation Violated:

A. Except for an outdoor behavioral health care program provided by a behavioral health residential facility, an administrator shall ensure that:
14. Poisonous or toxic materials stored by the behavioral health residential facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;

Evidence/Findings:

Based on observation and interview, the administrator failed to ensure poisonous or toxic materials stored by the behavioral health residential facility was locked and inaccessible to residents. The deficient practice posed a risk to the health and safety of residents if materials were unlocked and accessible.

Findings include:

1. The Compliance Officer observed a bottle of "Lysol" toilet bowl cleaner unlocked in the bathroom of room four.

2. In an interview, E1 acknowledged the poisonous or toxic material was not locked and was accessible to residents.

Deficiency #17

Rule/Regulation Violated:

B. An administrator shall ensure that:
8. A resident bedroom complies with the following:
k. Has a clothing rod or hook in the bedroom designed to minimize the opportunity for a resident to cause self-injury.

Evidence/Findings:

Based on observation and interview, the administrator failed to ensure a resident bedroom had a clothing rod or hook designed to minimize the opportunity for a resident to cause self-injury. The deficient practice posed a ligature risk to residents.

Findings include:

1. The Compliance Officer observed a wooden clothing rod in the master bedroom of the facility. The wooden clothing rod did not give way when downward pressure was applied.

2. The Compliance Officer observed a wooden clothing rod in bedroom #3. The wooden clothing rod did not give way when downward pressure was applied.

3. In an interview, E1 acknowledged the wooden clothing rods did not minimize the opportunity for a resident to cause self-injury.

Deficiency #18

Rule/Regulation Violated:

R9-10-113. Tuberculosis Screening
A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that:
2. Include:
a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of:
i. Assessing risks of prior exposure to infectious tuberculosis,
ii. Determining if the individual has signs or symptoms of tuberculosis, and
iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1);

Evidence/Findings:

Based on record review and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening consisting of assessing risks of prior exposure to infectious TB, determining if the individual had signs or symptoms of TB, and the individual's freedom from infectious TB. The deficient practice posed a potential TB exposure risk to residents.

Findings include:

R9-10-113.B.1.c.(i-ii) B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: c. If the individual had a positive Mantoux skin test or other tuberculosis screening test according to subsection (B)(1)(a) and does not have history of tuberculosis or documentation of latent tuberculosis infection, as defined in A.A.C. R9-6-1201, a written statement: i. ii. That the individual is free from infectious tuberculosis, signed by a medical practitioner or local health agency, as defined in A.A.C. R96-101; and Dated within 12 months before the date the individual begins providing services at or on behalf of the health care institution or is admitted to the health care institution.

1. A review of E2's personnel record revealed a negative Mantoux skin test dated October 3, 2022. However, a second negative TB screening test and baseline screening assessing risks or prior exposure to infectious TB was not available for review.

2. A review of E3's personnel record revealed a negative Mantoux skin test dated July 22, 2022. However, a second negative TB screening test and baseline screening assessing risks or prior exposure to infectious TB was not available for review.

3. A review of E5's personnel record revealed a negative Mantoux skin test dated January 4, 2023 and February 1, 2023. However, a baseline screening assessing risks or prior exposure to infectious TB was not available for review.

4. In an interview, E1 acknowledged the administrator failed to ensure a personnel record was maintained for each personnel with documentation of freedom from infectious TB in compliance with R9-10-113.

Facility Information

Inspection History

INSP-0130548

Summary:

Deficiencies Found: 10

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #9

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #10

Rule/Regulation Violated:

Evidence/Findings:

INSP-0058730

Summary:

Deficiencies Found: 18

Deficiency #1

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #2

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #3

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #4

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #5

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #6

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #7

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #8

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #9

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #10

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #11

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #12

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #13

Rule/Regulation Violated:

Evidence/Findings:

Deficiency #14

Rule/Regulation Violated: