Aloha Assisted Living LLC

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Finding included: 1. A review of facility documentation revealed that the policies and procedures were last reviewed on July 22, 2022 by the former facility manager. Documentation was not available showing the review and signature of the current facility manager. 2. In an exit interview, findings were discussed with E2 and no additional information was provided.

Based on observation, documentation review, and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed that the facility provided medication administration services. 2. A review of the facility's policies and procedures revealed a policy titled “Medication.” However, the medication policies and procedures were not reviewed, signed, and dated by a medical practitioner, registered nurse, or pharmacist. 3. In an exit interview, the findings were reviewed with E2 and no additional information was provided.

Based on documentation review, and interview, a manager failed to implement policies and procedures to protect the health and safety of a resident that covered methods by which an assisted living center was aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living center is authorized to provide. Findings Include: 1. A review of facility documentation revealed a policy titled "Wandering Policy." The policy states "Residents who wander place their health and safety at risk if they should leave and get lost. All personnel will make every attempt to keep residents from wandering away from the facility by: Following the steps outlined in this procedure. ...10. If a resident does wander from the facility and is not located immediately the following measures will be taken....B. notify local law enforcement of the lost resident....D. Provide sufficient personnel to search the neighborhood door to door resolution. 2. A review of facility documentation incident report dated October 11, 2024 at 7:00 PM. The incident report revealed [...R1 stepped out of the home to walk around the neighborhood around 7:00 PM and R1 was not able to find their way back to the facility. The facility called the police station and patrol cars to go look for R1, R1 was located on Mckellips Rd and was returned back to the facility at 10:00 PM.] A review of incident report revealed another incident report dated October 12, 2024 at 6:30 PM. The incident report revealed [...R1 left the facility at 5:11 PM and came back after 30 minutes. R1 then left the facility again at 6:30 PM saying R1 needed to go to the barber shop and R1 did not return to the facility, the facility reported R1 missing to the police station. R1 was found on almost on the freeway and was returned to the 9:10 PM.] The facility documentation incident report does not indicate if the staff at the facility went door to door to locate R1. 3. In an interview, E1 and E5 reported facility staff allowed R1 to leave the facility unsupervised twice. E1 and E5 acknowledge the facility did not report the missing resident to law enforcement immediately and did not provide sufficient personnel to search the neighborhood door to door resolution. E1 and E5 reported R1 had issues with leaving the other facility they were at and R1 was place at this current facility.

Based on documentation review, observation, record review, and interview, the manager failed to ensure an assistant caregiver interacted with residents under the supervision of a manager or caregiver. The deficient practice posed a risk as E4 was not qualified to provide the required services unsupervised. Findings include: 1. Arizona Revised Statutes (A.R.S.) \'a7 36-401(A)(49) states "[s]upervision" means "directly overseeing and inspecting the act of accomplishing a function or activity." 2. During the environmental inspection of the facility, the Compliance Officers observed E4 working at the facility and providing direct services to R4 without being under the direct supervision of a caregiver or manager. 3. A review of E4's personnel record revealed E4 was hired as an assistant caregiver. There was no documentation in E4's personnel record to indicate E4 completed an approved caregiver training program. 4. In an interview, E1 and E5 acknowledged E4 was an assistant caregiver and E4 provided services to residents without being under the direct supervision of a caregiver or manager.

Based on documentation review, record review, and interview, the manager failed to ensure a medical record was maintained for one former resident according to A.R.S. Title 12, Chapter 13, Article 7.1. The deficient practice posed a risk as required information could not be verified for the sampled resident. Findings include: 1. A.R.S. \'a7 12, Chapter 13, Article 7.1 states, "Unless otherwise required by statute or by federal law, a health care provider shall retain the original or copies of a patient's medical records as follows: 1. If the patient is an adult, for at least six years after the last date the adult patient received medical or health care services from that provider." 2. The Compliance Officer requested R1's record for review. However, R1's medical record was not provided. 3. In an interview, E1 and E4 reported R1's medical record was unavailable for review at the time of the survey.

Based on documentation review and interview, the manager failed to ensure policies and procedures were established and documented for ensuring the safety of a resident who may wander. Findings Include: 1. A review of facility documentation revealed a policy titled "Wandering Policy." The policy states "Residents who wander place their health and safety at risk if they should leave and get lost. All personnel will make every attempt to keep residents from wandering away from the facility by: Following the steps outlined in this procedure. ...10. If a resident does wander from the facility and is not located immediately the following measures will be taken....B. notify local law enforcement of the lost resident....D. Provide sufficient personnel to search the neighborhood door to door resolution. 2. A review of facility documentation incident report dated October 11, 2024 at 7:00 PM. The incident report revealed [...R1 stepped out of the home to walk around the neighborhood around 7:00 PM and R1 was not able to find their way back to the facility. The facility called the police station and patrol cars to go look for R1, R1 was located on Mckellips Rd and was returned back to the facility at 10:00 PM.] A review of incident report revealed another incident report dated October 12, 2024 at 6:30 PM. The incident report revealed [...R1 left the facility at 5:11 PM and came back after 30 minutes. R1 then left the facility again at 6:30 PM saying R1 needed to go to the barber shop and R1 did not return to the facility, the facility reported R1 missing to the police station. R1 was found on almost on the freeway and was returned to the 9:10 PM.] The facility documentation incident report does not indicate if the staff at the facility when door to door to located R1. 3. In an interview, E1 and E5 reported facility staff allowed R1 to leave the facility unsupervised twice. E1 and E5 acknowledge the facility did not report the missing resident to law enforcement immediately and did not provide sufficient personnel to search the neighborhood door to door resolution. E1 and E5 reported R1 had issues with leaving the other facility they were at and R1 was place at this current facility.

Based on record review and interview, the manager failed to ensure a written service plan for a resident receiving directed care services was reviewed and updated at least once every three months, for one of one resident sampled who received directed care services. Findings include: 1. A review of R1's medical record revealed a written service plan for directed care services, dated March 11, 2023. However, a more recent service plan was not available for review. 2. In a joint interview, E2 and E3 acknowledged R1's service plan was not reviewed and updated at least once every three months.

Based on record review and interview, the manager failed to ensure a caregiver provided a resident with the assisted living services in the resident's service plan, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a written service plan for directed care services, dated March 11, 2023. The service plan included a section titled "BATHING," which indicated R1 was to receive assistance with "Shower: 3X per week, Wash hair: 3X week." 2. Further review of R1's medical record revealed documents titled "Activities of Daily Living" (ADL) for June 2023. A column on the left side of R1's June ADL stated, "Shower per week: 2x, Hair was [sic] per week: 1x, Full assistance." The document revealed R1 received assistance with showering on June 1-3, 8, 15, 21, 24, and 29, 2023. The document indicated R1 received assistance with hair washing on June 1, 8, 15, 21, 24, and 29, 2023. However, documentation showing R1 received assistance with "Shower" and "Wash hair" three times per week as specified in R1's service plan was not available for review. 3. In an interview, E3 reported R1 often refused assistance with showering. E3 reported R1 received assistance with showering at least once a week, and R1's hair was usually washed when R1 was showered. E3 acknowledged R1 was not provided with services as specified in R1's service plan. 4. A review of R2's medical record revealed a written service plan for personal care services, dated March 30, 2023. The service plan included a section titled "BATHING," which indicated R1 was to receive assistance with "Shower: 3X per week, Wash hair: 3X per week." 5. Further review of R2's medical record revealed documents titled "Activities of Daily Living" (ADL) for June 2023. A column on the left side of R2's June ADL stated, "Shower per week: 2x, Hair was [sic] per week: 2x, assistance." The document revealed R2 received assistance with showering and washing hair on June 1, 6, 8, 17, 22, 24, 27, and 30, 2023. However, documentation showing R2 received assistance with "Shower" and "Wash hair" three times per week as specified in R2's service plan was not available for review. 6. In an interview, E3 reported R2 received assistance showering twice per week. E3 reported R2 received assistance washing R2's hair each time R2 was showered. E3 acknowledged R2 was not provided with services as specified in R2's service plan.