Bright Valley Grouphome, L L C

Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that monitored or alerted employees of the egress of a resident from the facility. This deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of Department documentation revealed the facility was licensed to provide directed care services. 2. During an environmental tour, the Compliance Officers observed the following exit door did not contain working alerts: An unmonitored exit door in a resident’s room that led to the backyard.  3. In an interview, E1 reported that E1 would get the alarm fixed. 4. In an exit interview, the findings were discussed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents included all individuals on the premises. Findings include: 1. A review of facility documentation revealed evacuation drills were conducted on February 2, 2023 and August 2, 2023. However, the document revealed residents were not evacuated. 2. In an interview, E1 reported E1 had not evacuated residents in the above mentioned evacuation drills.

Based on documentation review and interview, the health care institution's chief administrative officer shall failed to ensure the health care institution established, documented, and implemented tuberculosis infection control activities consistent with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel: Recommendations from the National Tuberculosis Controllers Association and CDC, 2019, published by the U.S. Department of Health and Human Services, Atlanta, GA 30333, available at https://www.cdc.gov/mmwr/volumes/68/wr/mm6819a3.htm, incorporated by reference, on file with the Department, and including no future editions or amendments. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "INFECTION CONTROL" (dated in August 2022). The procedure revealed the "TB SCREENING" section was not complianct with R9-10-113. 2. In an interview, E1 reported E1 reported the facility had not established, documented and implemented tuberculosis infection control activities as specified in R9-10-113. Technical assistance was provided on this Rule during the compliance inspection completed on August 22, 2022.

Based on record review and interview the health care institution's chief administrative officer failed to ensure establish, document and implement tuberculosis infection control activities to include annual training and education related to recognizing the signs and symptoms of tuberculosis (TB) to individuals employed by the health care institution. Findings include: 1. A review of E1's, E2's, and E3's personnel records revealed training and education related to recognizing the signs and symptoms of TB was not available for review. 2. In an interview, E1 acknowledged the above mentioned personnel records had not included documentation of TB training and education. E1 reported the facility had not established, documented and implemented tuberculosis infection control activities as specified in R9-10-113. Technical assistance was provided on this Rule during the compliance inspection completed on August 22, 2022.