Anthem Senior Manor

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of five employees reviewed, which required an employee to have a valid fingerprint clearance card or submitted an application for a fingerprint clearance card no more than 20 working days after the date of hire. The deficient practice posed a risk if the employee was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "A... 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 or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or 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 valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work..." 2. Review of E2's personnel record revealed E2 worked as a facility caregiver and had a hire date of February 27, 2023. The personnel record revealed no documentation of a fingerprint clearance card, or that an application for a fingerprint clearance card was submitted to the Department of Public Safety. 3. In an interview, E1 acknowledged E2's personnel record did not include documentation of a fingerprint clearance card or an application for a fingerprint clearance card.

Based on observation, interview, and documentation review, the manager failed to ensure policies and procedures were established, documented, and implemented covering job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk as there were no policies and procedures to reinforce and clarify the health care institution's standards. Findings include: 1. When the Compliance Officer arrived at the facility, E4 was observed at the facility. 2. In an interview, E4 reported E4 assisted with cleaning and laundry. 3. Review of the facility's policies and procedures revealed no policy and procedure for a housekeeper. 4. In an interview, E1 reported E4 worked as a housekeeper and acknowledged a policy and procedure was not available covering job descriptions, duties, and qualifications, including required skills and knowledge, education, and experience for a housekeeper.

Based on observation, interview, and record review, the manager failed to ensure a personnel record was established and maintained for each employee as required. The deficient practice posed a risk as required information could not be verified for E4, and the Department was provided false and misleading information. Findings include: 1. When the Compliance Officer arrived at the facility, E2, E3, and E4 were the only employees at the facility. 2. In an interview, E2 reported E4 worked as an assistant caregiver. 3. In an interview, E1 reported E4 just started yesterday and worked as a housekeeper. 4. Review of R2's medical record revealed an electronic document titled "ADL Log" dated September 2023. This log revealed E4 assisted R2 with ambulation, bowel care, incontinence care, and grooming tasks on September 4th. 5. In an interview, E4 reported E4 only assisted with cleaning and laundry. E4 reported E4 had come to the facility a few days prior and a caregiver showed E4 around, however E4 started yesterday. 6. Review of the personnel records revealed no record for E4. 7. In an interview, E1 acknowledged a personnel record was not established for E4.