Danville Services of Arizona - Catalina Home

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 in compliance with the rule: a. Documentation of the initial assessment required in R9-10-2207(3) to determine acuity, as an initial assessment had been conducted for each resident, but these did not include a determination of acuity; b. Documentation of the resident's comprehensive assessment required in R9-10-2214.A, for R2; c. A copy of R1's guardianship; d. Individual program plans, including nursing care plans or medical care plans, if applicable, as required in R9-10-2214.B, for R2; e. Documentation of physical health services provided to the resident, as some tasks were being tracked, but other physical health services had not been documented; f. A copy of R1's Advanced Directive; g. Documentation of freedom from infectious tuberculosis required in R9-10-2207(10); and h. Documentation of medication administered to each resident, as R2's medication administration record did not include vital signs documentation necessary to evaluate a parameter for administration for all administered doses of the medication. 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, the administrator failed to designate, in writing, an individual who is present on the premises of the nursing-supported group home and accountable for the nursing-supported group home when the administrator is not present on the nursing-supported group home's premises. Findings include: 1 . Upon arriving at the facility, the Compliance Officer observed the administrator was not present on the nursing-supported group home's premises. The Compliance Officer observed three staff, including a Practical Nurse, and two direct service professionals, were present at the facility. 2. A review of facility documentation revealed documentation of the administrator's designees was not available for review. 3. In an interview, E1 and E2 acknowledged documentation of the administrator's designees was not available for review.

Based on documentation review and interview, the administrator did not ensure the disaster plan was reviewed at least once every 12 months. Findings include: 1 . A review of facility documentation revealed a disaster plan. However, documentation of the disaster plan being reviewed at least once every 12 months was not available for review. 2 . In an interview, E1 and E2 acknowledged documentation of the disaster plan having been reviewed at least once every 12 months was not available.

Based on documentation review and interview, the administrator failed to ensure a documented report was submitted to the governing authority which included an identification of each concern about the delivery of services related to resident care, and any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care. Findings include: During the on-site inspection, the Compliance Officer requested to review a current quality management report. However, a quality management report was not provided for review. In an interview, E1 and E2 acknowledged a quality management report had not been provided for review.

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. The deficient practice posed a risk as required information could not be verified for E4, E5, and E6. 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 o

Based on documentation review and interview the Administrator failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of the facility work schedule revealed the facility worked three shifts per day, a first shift from 6 AM to 2 PM, a second shift from 2 PM to 10 PM, and a third shift from 10 PM to 6 AM, Monday through Friday, with modified 12 hour shifts on the weekends. 2. A review of facility documentation revealed documentation of a disaster drills for employees conducted as follows: July 4, 2024 at 1 PM; August 5, 2024 at 10:00 AM; September 4, 2024 at 9:30 AM; October 5, 2024 at 9:00 AM; November 4, 2024 at 9:00 AM; December 2, 2024 at 10:00 AM; January 3, 2025 at 9:00 AM; February 3, 2025 at 4:00 PM; and March 5, 2025 at 12:00 AM. 3. In an interview, E1 and E2 acknowledged disaster drills had not been conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the administrator failed to ensure an evacuation drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility documentation revealed evacuation drills had been conducted as follows: June 5, 2024 at 11:00 AM; July 5, 2024 at 1:00 PM; August 5, 2024 at 10:00 AM; September 4, 2024 at 9:00 AM; October 5, 2024 at 10:00 AM; November 4, 2024 at 9:00 AM; December 2, 2024 at 10:00 AM; January 3, 2025 at 9:00 AM; February 3, 2025 at 4:00 AM; and March 5, 2025 at 12:00 AM 2. In an interview, E1 and E2 acknowledged an evacuation drill for employees had not been conducted on each shift at least once every three months and documented.

Based on observation and interview, the administrator failed to ensure a fire extinguisher was inaccessible to residents, and failed to ensure smoke detectors were Tested at least once a month, with documentation of the test maintained for at least 12 months after the date of the test. Findings include: During an environmental tour of the facility, the Compliance Officers observed a wall-mounted fire extinguisher in the dining room adjacent to office was accessible to anyone, including residents. A review of facility documentation revealed monthly tests of the facility smoke detectors was not available for review. In an interview, E1 and E2 acknowledged a fire extinguisher was accessible to residents and documentation of monthly smoke detector tests 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: 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. In an interview, E1 reported the facility had not obtained a fire inspection. In an interview, E1 and E2 acknowledged documentation of a current fire inspection had not been provided for review.