Caring Hearts Assisted Care Home

Based on record review, observation, and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of one residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. The deficient practice posed a risk as false or misleading documentation was provided to the department. Findings include: 1. A review of R1's medical record revealed a personal care service plan, dated September 26, 2024, that indicated R1 would receive the following services: - Housekeeping: Total Assist one time per week; - Dressing - Total and partial assist two times per week; - Shave Face - Total Assist one time per week; - Bathing - Total Assist two times per week; - Skin Assessment - Total Assist one time per week; and - Mobility - Partial assist with transfers. However, no documentation of services being provided to R1 per R1's service plan was available for review. 3. In an interview, E1 reported R1 received all assisted living services included in R1's service plan. E1 acknowledged a caregiver failed to document the services provided in R1's medical record.

Based on record review and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training for one of two personnel sampled. The deficient practice posed a health and safety risk for residents. Findings Include: 1. A review of E2's personnel record revealed no documentation was available verifying completion of fall prevention and fall recovery training. 3. In an interview, E1 acknowledged the health care institution did not administer a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training.

Based on record review and interview, the manager failed to ensure a standardized emergency responder patient information form as described in subsection A of this section, was completed and maintained for one of one resident sampled. The deficient practiced posed a risk as required patient information was not prepared in case of an emergency. Findings include: 1. A review of R1's medical records revealed documentation of a standardized emergency responder patient information form completed as required by Arizona Revised Statute (A.R.S.) \'a7 36-420.04(A)(1) through (9). However, a copy of R1's health insurance portability and accountability act (HIPAA) release authoring a receiving hospital to communicate with the adult foster care home and medication list were not included for review. 2. In an interview, E1 reported E1 was not aware of the HIPAA release requirement. E1 acknowledged the information required in A.R.S. \'a7 36-420.04 was not prepared in a standardized emergency responder patient information form as required.

Based on record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for one of two employees reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that...2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1)..." 2. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. A review of E2's personnel record revealed completion of two-step TST testing. However, no documentation of a baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the E2 had signs or symptoms of TB was available for review. 4. In an interview, E1 acknowledged E2 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or before the date E2 began providing services at or on behalf of the assisted living facility.

Based on observation and interview, the manager failed to ensure a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. During an environmental inspection of the facility, the compliance officer observed a sliding door leading out to the backyard patio. The door was equipped with an alarm at the top of the door frame. However, the alarm was turned off. 2. In an interview, E1 acknowledged the door leading to the backyard patio did not control or alert employees of the egress of a resident from the facility.

Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening, for one of two sampled personnel. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. Arizona Administrative Code (A.A.C.) R9-10-113(B)(1)(a)(i) states: "B. A health care institution's chief administrative officer shall: 1. For an individual for whom baseline screening and documentation of freedom from infectious tuberculosis is required by an Article in this Chapter, as specified in subsection (A)(2)(a), obtain one of the following as evidence of freedom from infectious tuberculosis: a. Documentation of a negative Mantoux skin test or other tuberculosis screening test that: i. Is recommended by the U.S. Centers for Disease Control and Prevention (CDC)." 2. A review of the CDC website revealed a web page titled "Baseline Tuberculosis Screening and Testing for Health Care Personnel." The web page stated: "If the Mantoux tuberculin skin test (TST) is used for baseline testing of health care personnel, use two-step testing. Purpose: Two-step testing is recommended for the initial TB skin test for adults who may be tested periodically, such as health care personnel." 3. A review of E2's personnel record revealed completion of two-step TST testing. However, no documentation of a baseline screening consisting of assessing risks of prior exposure to infectious TB and determining if the E2 had signs or symptoms of TB was available for review. 4. In an interview, E1 acknowledged the chief administrative officer failed to implement tuberculosis (TB) infection control activities including baseline screening.

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for two of two personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. A review of E1's and E2's personnel record revealed no documentation E1 and E2 completed training on recognizing the signs and symptoms of TB was available for review. 2. In an interview, E1 reported E1 was not aware of the requirement to complete the annual training. E1 acknowledged E1's and E2's personnel records did not include documentation of annual training on recognizing the signs and symptoms of TB.

Based on documentation review and interview, the health care institution failed to establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a TB exposure risk to residents and staff. Findings include: 1. A review of facility documentation revealed no documentation of annually assessing the health care institution's risk of exposure to infectious TB was available. 2. In an interview, E1 reported E1 had not completed the annual risk assessment. E1 acknowledged an assessment of the health care institution's risk of exposure to infectious TB was not conducted annually.