A Breath of Life Care Home LLC

Based on documentation review and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of two personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population. A.R.S. § 36-411.A states: "A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work." Findings include: 1. A review of E2's personnel record revealed E2 was hired as a caregiver in May of 2022. 2. A review of E2’s personnel record revealed a fingerprint clearance card (FCC) with an expiration date of October 24, 2025; however, no further documentation was available of a current FCC. 3. A review of facility documentation revealed E2 was on the work schedule every day for the month of October 2025, a total of 19 days for the month of November 2025, every day the month of December 2025, and every day for the month of January 2026. 4. In an exit interview, the findings were reviewed with E1. E1 acknowledged the personnel record provided for E2 did not include a valid FCC. E1 stated E1 would submit an application for the FCC for E2 immediately.

Based on record review and interview, the manager failed to ensure a residency agreement included whether the manager or a caregiver was awake during nighttime hours, for one of two residents sampled. Findings include: 1. A review of R2's medical records revealed a signed residency agreement. The residency agreements did not include documentation of whether the manager or a caregiver was awake during nighttime hours. 2. In an interview, E2 reported the agreement was a template and did not include the full statement regarding caregivers sleeping at night. E2 acknowledged R2's residency agreement did not include whether the manager or a caregiver was awake during nighttime hours.

Based on record review and interview, the manager failed to ensure a resident, receiving directed care services, had a written service plan that was reviewed and updated at least once every three months, for one of two resident records reviewed. Findings include: 1. A review of R2's medical record revealed a service plan for directed care services dated July 18, 2023. Based on the date of R2's service plan, a reviewed and updated service plan was required on or before October 18, 2023. No updated service plan was available for review. 2. In an interview, E1 acknowledged the medical record provided for R2 did not include the required service plan update at least once every three months.