A Place All My Own Terracina

Based on documentation review, record review, and interview, the administrator failed to develop and administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed no training program for all staff regarding fall prevention and fall recovery. 2. A review of the personnel records of E3, E4, and E5 revealed no documentation of training on fall prevention and fall recovery. 3. In an interview, E1 reported being unaware of this statute.

Based on documentation review, record review, and interview, the administrator failed to ensure the nursing-supported group home's compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(C)(1) and (2), for three of three personnel members sampled. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population, or was unqualified to work in a residential care institution. Findings include: 1. A.R.S. \'a7 36-411(C) states: "C. Owners shall make documented, good faith efforts to: 1. 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. 2. Verify the current status of a person's fingerprint clearance card." 2. A review of facility documentation revealed a policy and procedure titled "Staff File Index." The policy and procedure stated: "Section I: Staff Information...3. Verified references: 3 non-relative...5. Fingerprint clearance card (front and back) [and] 6. Fingerprint Verification Record." 3. A review of E3's personnel record revealed E3 was hired as a nurse. The review revealed a photocopy of E3's fingerprint clearance card. However, the review revealed no documentation of compliance with A.R.S. \'a7 36-411(C)(2). 4. A review of E4's personnel record revealed E4 was hired as a nurse. The review revealed documentation of two references. However, the individuals were personal references and not previous employers as required by A.R.S. \'a7 36-411(C)(1). The review revealed a photocopy of E4's fingerprint clearance card. However, the review revealed no documentation of compliance with A.R.S. \'a7 36-411(C)(2). 5. A review of E5's personnel record revealed E5 was hired as a nurse. The review revealed documentation of two references. However, the individuals were personal references and not previous employers as required by A.R.S. \'a7 36-411(C)(1). The review revealed a photocopy of E5's fingerprint clearance card. However, the review revealed no documentation of compliance with A.R.S. \'a7 36-411(C)(2). 6. A review of the Arizona Department of Public Safety (DPS) fingerprint clearance card verification website revealed E3's, E4's, and E5's fingerprint clearance cards were valid. 7. In an interview, E1 reported prospective personnel bring their own references. E1 reported the governing authority did not contact previous employers to obtain information or recommendations that may have been relevant to E3's, E4's or E5's fitness to work in a residential care institution. E1 further reported the governing authority has not verified employees' fingerprint clearance cards. 8. A review of facility documentation revealed an email from E2 to E1. The email stated, "Here's the FP validations." The email contained verification of the fingerprint clearance cards of E3, E4, and E5 in the form of web page screenshots. However, the "document properties" page revealed the screen

Based on observation, record review, and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented before the personnel member provided physical health services, habilitation services, or behavioral care, for two of three personnel members sampled. The deficient practice posed a risk if a personnel member did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed E3 providing physical health services. 2. A review of R2's medical record revealed a medication administration record (MAR) dated February 2024. The MAR revealed E3 and E5 provided medication services to R2 multiple times throughout February 2024. 3. A review of E3's personnel record revealed E3 was hired as a nurse. However, the review revealed no documentation of E3's skills and knowledge. 4. A review of E5's personnel record revealed E5 was hired as a nurse. However, the review revealed no documentation of E5's skills and knowledge, other than a document reporting E5 participated in a "Vent and Trach Class" on January 4-5, 2024. 5. In an interview, E1 stated, "I don't have the skills and knowledge for [E3]."