Called to Care Residential Facility, LLC Gh 3

Based on documentation review and interview, the administrator failed to ensure policies and procedures were established, documented, and implemented to protect the health and safety of a resident as required in R9-10-2203 (C)(1)(2). Findings include: 1. A review of the facility's policies and procedures revealed a policy titled “Staff Training, Skills and Qualifications.” However, the policy did not include complete job descriptions or specify the required skills, knowledge, education, and experience for personnel members, employees, volunteers, and students, as required by R9-10-2203(C)(1)(a). 2. A review of the facility’s policies and procedures revealed a policy titled “Staff Training, Skills and Qualifications.” The policy stated, “Staff member's files will have documentation showing they have been oriented to all members they are providing services for within fourteen (14) days of hire.” However, R9-10-2206(K)(2) states orientation must be completed before a personnel member provides services to a resident. 3. A review of the facility's policies and procedures revealed a policy titled “Staff Training, Skills and Qualifications.” However, the policy did not cover the following required trainings: - Restraint training per R9-10-2206(I)(3)(h), to include Prevention and Support training; - Training by nursing staff for other employees on recognizing signs of illness or injury per R9-10-2215(B)(3)(b); - Training for non-nurses in assistance in the self-administration of medications per R9-10-2221(C)(4); - Training in infection control procedures per R9-10-2223(3)(f); - Training on the disaster plan per R9-10-2224(A)(2); - Initial and Annual TB education per R9-10-113(A)(2)(c); and - Initial and Annual Fall prevention and Fall Recovery training per ARS 36-420.01. 4. A review of the facility's policies and procedures revealed documentation of a policy covering ARS Title 36, Chapter 4, Article 11 (ARS 36-450) was not available for review. 5. A review of the facility's policies and procedures revealed a policy titled Staff Training, Skills and Qualifications which covered cardiopulmonary resuscitation (CPR). However the policy did not include in detail; which personnel members are required to obtain CPR training; the method and content of CPR training; demonstration of the ability to perform CPR; the qualifications for an individual to provide CPR training. In addition the policy did not specify CPR training must include pediatric or infant CPR, despite the facility serving residents under the age of 18. 6. A review of the facility's policies and procedures revealed policies covering the following topics were not available for review; - Include a method to identify a resident to ensure the resident receives physical health services, habilitation services, and behavioral care as ordered; - Cover resident rights, including assisting a resident who does not speak English or who has a disability to become aware of resident rights; - Cover specific steps

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel record was maintained for each personnel member to include all required documentation, for three of three sampled personnel members. Arizona Revised Statutes (ARS) § 36-406 states: ARS § 36.411 states: "A. Except as provided in subsection F of this section, 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, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work. B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. C. Each residential care institution, nursing care institution and home health agency 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. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to s

Based on record review and interview, the administrator failed to ensure a resident's medical record contained all required documentation for two of two residents sampled. Findings include: 1. A review of R1's and R2's medical records revealed the following documents were not provided for review: a. Documentation of the initial assessment required in R9-10-2207(3) to determine acuity; b. The medical history and physical examination required in R9-10-2215(A)(2); c. Documentation of the resident's comprehensive assessment required in R9-10-2214.A; d. Individual program plans, including nursing care plans or medical care plans, if applicable, as required in R9-10-2214.B; e. Documentation of physical health services provided to the resident; f. Documentation of laboratory reports, radiologic reports, diagnostic reports, and consultation reports as applicable for each medical provider visit; and g. Documentation of freedom from infectious tuberculosis required in R9-10-2207(10). 2. In an interview, E1 acknowledged the medical records provided for R1 and R2 did not include all required documentation.

Based on observation, documentation review, and interview, the administrator failed to ensure a menu was conspicuously posted, included any food substitution no later than the morning of the day of meal service with a food substitution, and was maintained for at least 60 calendar days after the last day included in the food menu. Findings include: During an environmental inspection of the facility, the Compliance Officers observed a food menu was not posted in the facility. The Compliance Officers requested a 60 day record of food served at the facility, however these records were not available for review. In an interview, E1 acknowledged the menu was not posted and historical menus including substitutions for the previous 60 days had not been provided for review.

Based on observation and interview, the administrator failed to ensure a fire extinguisher was inaccessible to residents, and failed to ensure smoke detectors were installed in the laundry room and attached garage. Findings include: During an environmental tour of the facility, the Compliance Officers observed a wall-mounted fire extinguisher in the dining room adjacent to the kitchen was accessible to anyone, including residents. During an environmental tour of the facility, the Compliance Officers observed a laundry room did not contain a smoke detector. During an environmental tour of the facility, the Compliance Officers observed an attached garage did not contain a smoke detector. In an interview, E1 acknowledged the fire extinguisher was accessible to residents and the laundry room and garage did not have smoke detectors. E1 reported for residents who are able to cook their own food in the kitchen, they should have access to the fire extinguisher for their own safety while cooking.

Based on observation and interview, the administrator failed to ensure hot water temperatures were maintained between 95° F and 120° F. Findings include: During an environmental inspection of the facility, the Compliance Officer measured the water temperature at the kitchen sink was 127° F. In an interview, E1 acknowledged the water temperature had not been maintained between 95° F and 120° F.