Best Choice 2 Assisted Living Home

Based on documentation review and interview, the manager failed to ensure that 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. 1. A review of the facility notes revealed the facility was given technical assistance on June 25, 2023, and the Compliance Officer was informed at the time that the policies and procedures were being updated. 2. A review of policies and procedures revealed they were last reviewed on January 17, 2020. 3. In an interview, E1 acknowledged that policies and procedures were not reviewed at least once every three years.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(2), for one of two caregivers sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population. Findings include: A.R.S. \'a7 36-411(C)(2) Owners make documented, good faith efforts to: Verify the current status of a person's fingerprint clearance card. 1. A review of E3's (hired in 2023) personnel record revealed documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(2) was not available for review. 2. In an interview, E1 acknowledged documentation to demonstrate E3's documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(2) was not available for review.

Based on record review and interview, the manager failed to ensure before or at the time of acceptance of an individual, the individual submitted documentation dated within 90 calendar days before the individual was accepted by the assisted living facility to include whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints; dated and signed by a physician, registered nurse practitioner, registered nurse or physician assistant, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's medical record revealed documentation for the requirements in R9-10-807(B)(1). However, the documentation was signed and dated four calendar days after R1's date of acceptance. 2. In an interview, E1 acknowledged the documentation was not submitted before or at the time of R1's acceptance.