Danville Services of Arizona - Craycroft Home

Based on documentation review and interview, the administrator failed to ensure an acuity plan was developed, documented, and implemented. Findings include: 1. During an on-site inspection, the Compliance Officers requested to review the facility acuity plan. However, an acuity plan was not provided for review. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 11, 2024.

Based on documentation review and interview, the administrator failed to ensure an organizational chart had been updated as necessary. Findings include: 1. A review of the facility documentation revealed an organizational chart. 2. A review of the facility work schedule revealed multiple staff working at the facility were not on the organizational chart. 3. In an interview, E1 reported there have been some staffing changes and the organizational chart was not up to date. 4. In an exit interview, the findings were reviewed with E1 and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 11, 2024.

Based on documentation review and interview, the administrator failed to ensure documentation of the nurses and personnel members present each day included all required information. Findings include: 1. A review of facility documentation revealed a work schedule. However, the work schedule did not indicate the number of residents present each day, included an open shift, and was dated February 22, 2024. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 11, 2024.

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. The deficient practice posed a risk as the required information could not be verified. 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 resident's comprehensive assessments required in R9-10-2214(A); b. Individual program plans, including nursing care plans or medical care plans, if applicable, as required in R9-10-2214(B); c. Documentation of physical health services provided to the resident; d. Documentation of freedom from infectious tuberculosis required in R9-10-2207(10); and e. Documentation of a health care power of attorney or a copy of the court order establishing guardianship. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. This is a repeat deficiency from the on-site compliance inspection conducted on April 11, 2024.

Based on observation and interview, the administrator failed to ensure medication was stored in a locked area. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a refrigerator which was locked with a combination lock. However, the lock had been left on the unlock code, and the Compliance Officers were able to open the refrigerator without the code. Inside the refrigerator, the Compliance Officers observed resident medications including boxes of insulin. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

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 Officers 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 exit interview, the findings were reviewed with E1 and no additional information was provided. Technical assistance was provided for this rule during the on-site compliance inspection conducted on April 11, 2024.

Based on observation and interview, the administrator failed to ensure a food menu was posted. Findings include: 1. During an environmental inspection of the facility, the Compliance Officers observed a food menu was not posted in the facility. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review and interview, the administrator failed to 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 exit interview, the findings were reviewed with E1 and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 11, 2024.

Based on documentation review and interview, the administrator failed to ensure a disaster drill was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility disaster drills conducted during the previous twelve months revealed all drills occurred during the hours of the day shift. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 11, 2024.

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 evacuation drills conducted during the previous twelve months revealed all drills occurred during the hours of the day shift. 2. In an exit interview, the findings were reviewed with E1 and no additional information was provided. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 11, 2024.

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 cover job descriptions, duties, and qualifications, including required skills, knowledge, education, and experience for personnel members, employees, volunteers, and students, the process for checking on a personnel member through the adult protective services (APS) registry, orientation and in-service education, the requirements in A.R.S. Title 36, Chapter 4, Article 11, cardiopulmonary resuscitation training, first aid training, health care directives, a quality management program, personal accounts, petty cash funds, resident screening, admission, transport, transfer, discharge planning, and discharge, habilitation services, behavioral care, acuity, general consent and informed consent, preventing diversion of controlled substances, infection control, interventions, restraints, methods to encourage participation of a resident's family or friends, a method for obtaining an advocate for a resident, and the process for obtaining resident preferences. Findings include: 1. A review of the facility's policies and procedures revealed job descriptions for all positions were not available for review. Per R9-2206(B)(1-2), job descriptions are needed for skills verification. Job descriptions are also necessary to ensure all services listed in your scope or required by a resident are covered. 2. A review of the facility's policies and procedures (P&P) revealed APS registry checks are required on page 18 of the provided P&P, however, a policy covering how to check the APS registry and document the result was not available for review. 3. A review of the facility's policies and procedures revealed a policy covering orientation on page 19 of the provided P&P, however, the policy states, "within 14 days of hire, employees will also complete orientation in the home, including to the specific needs of clients," and does not require orientation before a personnel member provides services to a resident per R9-10-2206(K)(2) 4. A review of the facility's policies and procedures revealed a policy covering in-service education on page 19 of the provided P&P, however, the policy did not cover the following required training: - Restraint training per R9-10-2206(I)(3)(h); - 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); - Annual TB education per R9-10-113(A)(2)(c); and - Fall prevention and Fall Recovery training per ARS 36-420.01. 5. A review of the facility's policies and procedures revealed a policy covering ARS Title 36, Chapter 4, Article 11 (ARS 36-450) was not available for review. The P

Based on observation and interview, the administrator failed to ensure the nursing-supported group home had smoke detectors installed in each bedroom, storage room, and attached garage. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a smoke detector was not installed in R3's bedroom. 2. During an environmental tour of the facility, the Compliance Officers observed a smoke detector was not installed in the attached garage or in a storage room accessible from the garage. 3. In an interview, E1 acknowledged smoke detectors were not installed in all required locations.

Based on documentation review an interview, the administrator failed to obtain a fire inspection conducted according to the time-frame established by the local fire department or the State Fire Marshal, and maintain documentation of a current fire inspection. Findings include: 1. During the on-site inspection conducted on April 25, 2024, the Compliance Officers requested to review a current fire inspection conducted by the local fire department. However, a fire inspection was not provided for review. 2. In an interview, E1 acknowledged a current fire inspection 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 two of two sampled personnel members. The deficient practice posed a risk if employees were unable to meet a residents needs. Arizona Revised Statutes (ARS) \'a7 36-406 states: "In addition to its other powers and duties: 1. The department shall: (c) Have access to books, records, accounts and any other information of any health care institution reasonably necessary for the purposes of this chapter. 2. The department may: (a) Make or cause to be made inspections consistent with standard medical practice of every part of the premises of health care institutions which are subject to the provisions of this chapter as well as those which apply for or hold a license required by this chapter." ARS \'a7 36.424(C) states: "A. Except as provided in subsection B of this section, the director shall inspect the premises of the health care institution and investigate the character and other qualifications of the applicant to ascertain whether the applicant and the health care institution are in substantial compliance with the requirements of this chapter and the rules established pursuant to this chapter. C. ...Any application for licensure under this chapter constitutes permission for and complete acquiescence in any entry or inspection of the premises during the pendency of the application and, if licensed, during the term of the license. " R9-10-2203(C)(5)(a) states: "C. An administrator shall ensure that: 5. Unless otherwise stated: a. Documentation required by this Article is provided to the Department within two hours after a Department request; and" ARS \'a7 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 valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work. B. A health professional who has complied with the fingerprin

Based on documentation review, record review and interview, the administrator failed to ensure at the time of a resident's admission, a registered nurse conducted or coordinates an initial assessment on a resident to determine the resident's acuity and ensure the resident's immediate needs were met. Findings include: 1. A review of Department records revealed the facility was initially licensed as a Nursing Supported Group Home on February 24, 2023. 2. A review of the facility's policies and procedures revealed a policy N-13, titled, "Medical Records - Nursing Supported Group Homes" which stated, "An administrator shall ensure that a resident's medical record contains:....Documentation of the initial assessment required to determine acuity." 3. A review of R1's medical record revealed an admission date in May of 2023, after the facility was licensed as a Nursing Supported Group Home. 4. A review of R1's medical record revealed a nursing assessment, including a determination of R1's acuity to ensure R1's needs were met, was not available for review. 5. A review of R2's medical record revealed an admission date in May of 2022, prior to licensure. 6. A review of R2's medical record revealed a nursing assessment, including a determination of R2's acuity to ensure R2's needs were met, was not available for review. 7. In an interview, E1 acknowledged the medical records provided for R1 and R2 had not included nursing assessments to determine each resident's acuity.

Based on documentation review, record review and interview, the administrator failed to ensure a resident's medical record contained all required documentation, for two of two sampled residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy, N-13, which stated: "An administrator shall ensure that a resident's medical record contains: - Resident information that includes the resident's name, date of birth, and any known allergies (including medication allergies) - The admission date and, if applicable, the date of discharge - The admitting diagnosis or presenting symptoms - Documentation of the resident's placement evaluation - Documentation of the resident's individual service and program plan - Documentation of the resident's last periodic evaluation before the resident's admission and each periodic evaluation while the resident was admitted to the nursing-supported group home - Documentation of general consent and, if applicable, informed consent - If applicable, the name and contact information of the resident's representative and: - The document signed by the resident consenting for the resident's representative to act on the resident's behalf; or - If the resident's representative: - Has a health care power of attorney or a mental health care power of attorney, a copy of the health care power of attorney or mental health care power of attorney - Is a legal guardian, a copy of the court order establishing guardianship - The name and contact information of an individual to be contacted (the resident's representative, family member or other individual designated by the resident) - Documentation of the initial assessment required to determine acuity - The medical history and all physical examinations - A copy of the resident's living will or other health care directive, if applicable - The name and telephone number of the resident's designated medical practitioner - Physicians' orders - Documentation of the resident's comprehensive assessment - Individual program plans, including nursing/medical care plans, if applicable - Documentation of physical health services, habilitation services, and behavioral care provided to the resident - Progress notes, including data needed to evaluate the effectiveness of the methods, schedule, and strategies being used to accomplish the goals in the resident's individual program plan - If applicable, documentation of restraint or any actions other than restraint taken to control or address the individual's behavior to prevent harm to the resident or another individual or to improve the resident's social interactions - If applicable, documentation that evacuation from the nursing-supported group home would cause harm to the resident - Documentation of discharge to include discharge planning, discharge summary and the disposition of the resident after discharge - Transfer documentation - Any laboratory reports, radiologic reports, diagnostic reports, and consultation repo

Based on documentation review and interview, the administrator failed to ensure policies and procedures for medication services included a process for providing information to a resident or the resident's representative about the medication prescribed for the resident. Findings include: 1. A review of the facility's policies and procedures revealed a policy, N-3, titled, "Medication Administration Supports," revised November 7, 2022. However, the policy did not include a process for providing information to a resident or the resident ' s representative about medication prescribed for the resident including the prescribed medication's anticipated results, the prescribed medication ' s potential adverse reactions, the prescribed medication ' s potential side effects, and potential adverse reactions that could result from not taking the medication as prescribed. 2. In an interview, E1 reported the policies are centrally maintained and available electronically to all staff. E1 reported LTC275 uses the same electronic policies manual at LTC272.

Based on documentation review, 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 provides documentation to the resident ' s designated medical practitioner and the director of nursing indicating potential medication problems such as incompatible or duplicative medications. 1. A review of the facility's policies and procedures revealed a policy, N-9, titled, "Pharmacy Medication Reviews - Nursing Supported Group Homes," revised November 8, 2022. This policy stated, "Danville staff will request, review and document pharmacist reviews of resident medication at least once every three months. Documentation of quarterly medication reviews conducted by a pharmacist will be retained in the resident's medical record. A copy of the medication review will be distributed to both the resident's designated medical provider and Danville's Director of Nursing." 2. 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. 3. In an interview, E1 acknowledged the facility did not have a process to ensure a pharmacist reviewed each resident's medications at least once every three months. E1 reported LTC275 uses the same electronic policy and procedure manual as LTC272.