A LEGACY PERSONAL CARE HOME

A revisit survey was completed on 6/26/24 for all previous deficiencies cited on 2/6/24. The facility is in compliance with all deficiencies that were cited.

A relicensure survey was completed on 2/6/24. A deficiency was cited.

Based on record review and interview, the residence failed to ensure each personnel file included the required information, affecting three of three sample staff (#1-#3), affecting seven current residents. Findings include:1. Referencesa. Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein.b. Chapter VII regulations governing assisted living residences, part 7.8 (A), requires the assisted living residence shall ensure each staff member or volunteer completes an initial orientation prior to providing any care or services to a resident. Such orientation shall include, at a minimum, all of the following topics:(1) The care and services provided by the assisted living residence;(2) Assignment of duties and responsibilities, specific to the staff member or volunteer;(3) Hand Hygiene and infection control;(4) Emergency response policies and procedures, including:(a) Recognizing emergencies,(b) Relevant emergency contact numbers,(c) Fire response, including facility evacuation procedures(d) Basic first aid,(e) Automated external defibrillator (AED) use, if applicable,(f) Practitioner assessment, and(g) Serious illness injury, and/or death of a resident.(5) Reporting requirements, including occurrence reporting procedures within the facility;(6) Resident rights;(7) House rules;(8) Where to immediately locate a resident's advance directive; and(9) An overview of the assisted living residence's policies and procedures and how to access them for reference.c. Chapter VII regulations governing assisted living residences, part 7.8 (B), requires the assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, selfstudy courses, or on-the-job training, and shall include, but is not limited to, the following topics:(1) Overview of state regulatory oversight applicable to the assisted living residence;(2) Person-centered care;(3) The role of and communication with external service providers;(4) Recognizing behavioral expression and management techniques, as appropriate for the population being served;(5) How to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, as appropriate for the population being served;(6) Training related to fall prevention and ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobility;(7) How to safely provide lift assistance, accompaniment, and transport of residents;(8) Maintenance of a clean, safe and healthy environment including appropriate cleaning techniques;(9) Food safety; and(10) Understanding the staff or volunteer's role in end of life care including hospice and palliative care. Review of the personnel files for Staff #1-#3 revealed the following was not included in their files: Staff #1: Date of hire and date duties commenced, orientation and training. Staff #2: Date of hire and date duties commenced, orientation and training. Staff #3: Date of hire and date duties commenced, orientation and training, evidence of CBI and, CAPs check results, and CPR/First Aid. On 2/6/24 at 1:30 p.m., the administrator stated he was aware what documentation was required for personnel files. He stated the residence was in the process of transferring the personnel files into an electronic filing system, and that was why some of the required documentation was missing from the personnel files for Staff #1-#3. The administrator stated that all of the orientation and training documents were maintained in their training binder; however, the binder was currently not at the residence.