A Legacy Personal Care Home

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 o..