Danville Services of Arizona - Burns Home

Based on observation and interview, the administrator failed to designate, in writing, an individual who was present on the premises of the nursing-supported group home and accountable for the nursing-supported group home when the administrator was not present on the nursing-supported group home's premises. Findings include: 1. During the on-site inspection, the Compliance Officer observed the administrator was not present. 2. A review of the administrator's written designation of responsible individuals revealed a designation was not available for review. 3. In an interview, E1 acknowledged the administrator failed to identify, in writing, an individual who was present on the premises of the nursing-supported group home and accountable for the nursing-supported group home when the administrator was not present on the premises.

Based on documentation review and interview, the administrator failed to ensure an acuity plan was developed, documented, and implemented for the nursing-supported group home. Findings include: 1. During the on-site inspection, the Compliance Officer requested to review the facility's acuity plan. However, an acuity plan was not provided for review. 2. In an interview, E1 acknowledged an acuity plan was not provided for review.

Based on documentation review and interview, the administrator failed to ensure the facility's work scheduled included all of the required information. Findings include: 1. A review of the facility's work schedules revealed separate schedules for nurses and other personnel members were available. However, neither schedule included the number of residents, the certification or credential, if applicable, and the actual number of hours worked by each person. 2. In an interview, E1 acknowledged the provided work schedules did not include all of the required information.

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 available or were incomplete: a. Documentation of each resident's comprehensive assessment required in R9-10-2214.A; c. The name and contact information of an individual to be contacted under R9-10-2203(H)(1) for R1, as the contact information was known to be invalid for R1's emergency contact; d. Individual program plans, including nursing care plans or medical care plans, if applicable, as required in R9-10-2214.B, for both residents; e. Documentation of physical health services provided to each resident, as some tasks were being tracked, but other physical health services had not been documented; f. Each periodic evaluation, conducted according to A.A.C. R6-6-604, while the resident was admitted to the nursing-supported group home, as R2's periodic evaluation was dated July 2024; g. Documentation of freedom from infectious tuberculosis required in R9-10-2207(10); and h. Documentation of medication administered to each resident, as R1's medication administration record did not include vital signs documentation necessary to evaluate a parameter for administration for all administered doses of a medication. 2. In an interview, E1 acknowledged the medical records provided for R1 and R2 did not include all required documentation.

Based on record review, documentation review and interview, the administrator failed to ensure clinical laboratory services were provided through a laboratory which held a certificate of waiver. findings include: 1. A review of R2's medical record revealed R2 received insulin administration including finger-stick blood sugar (FSBS) testing. 2. During the on-site inspection, the Compliance Officer requested to review a valid Clinical Laboratories Improvement Act (CLIA) certificate of waiver permitting the use of waived FSBS devices. However, a CLIA waiver was not available for review. 3. In an interview, E1 acknowledged a current, valid CLIA waiver for the facility had not been provided for review.

Based on record review, and interview, the administrator failed to ensure policies and procedures for medication services were implemented to include procedures to ensure that a pharmacist reviews a resident's medications at least once every three months and provided documentation to the resident's designated medical practitioner and the director of nursing indicating potential medication problems such as incompatible or duplicative medications. Findings include: 1. A review of R1's and R2's medical record revealed the required pharmacist reviews, dated at least once every three months, were not available for review. 2. In an interview, E1 acknowledged the facility had not implemented a policy to ensure a pharmacist reviewed each resident's medications at least once every three months and had provided documentation to the resident's designated medical practitioner and the director of nursing indicating potential medication problems such as incompatible or duplicative medications.

Based on documentation review and interview, the administrator failed to ensure an infection control program had been established according to rule. Findings include: 1. During the on-site inspection, the Compliance Officer requested to review the facility's documentation of infections, analysis of the types, causes and spread of infections and communicable diseases, including infection control data and actions taken related to infections and communicable diseases. However, infection control program data and reports were not available for review. 2. In an interview, E1 acknowledged the facility had not established an infection control program.

Based on documentation review and interview, the administrator failed to ensure documentation of a disaster plan review was created and maintained. Findings include; 1. During the on-site inspection, the Compliance Officer requested to review a disaster plan review. However, this documentation was not available for review. 2. In an interview, E1 acknowledged a disaster plan review, compliant with the rule, had not been provided for review.

Based on documentation review and interview, the administrator failed to obtain and maintain a current fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal. Findings include: 1. During the on-site compliance and complaint inspection, the Compliance Officer requested to review a current fire inspection. However, a fire inspection was not provided for review. 2. In an interview, E1 reported the facility had not obtained a fire inspection. 3. In an interview, E1 and E2 acknowledged documentation of a current fire inspection had not been provided for review.

Based on staff interviews and review of facility documentation, the facility failed to ensure medications were reviewed by the pharmacist at least once every three months. Findings include: Review of facility documentation on February 06, 2024 at 1:00 p.m., revealed no evidence of pharmacist review done at least once every three months for all clients. In an interview with the licensed practical nurses (LPN, staff #1) conducted on February 06, 2024 at 1:00 p.m., she stated that the facility was aware of this issue but the pharmacy the facility uses no longer offers this service. She stated that they are in the process of hiring a new pharmacy.

Based on review of facility documentation and staff interviews, the facility failed to ensure disaster drills for employees was conducted and documented on each shift at least once every three months. Findings include: Review of the facility's disaster drill log for 2023 revealed that there were no disaster drills conducted. In an interview with the program director (staff # 8) conducted on February 06, 2024 at 1:00 p.m., she stated that a fire evacuation drill was done on October 19, 2023 but no disaster drill was performed. She further stated that she did not know that they had to conduct disaster drills. The policy on Disaster Evacuation Plan revealed that the fire drills shall be conducted on a monthly basis. However, the policy did not include any verbiage on conducting disaster drills.