Danville Services of Arizona - Eastland Home

Based on documentation review and interview, the administrator failed to designate, in writing, individuals who were 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. The Compliance Officer requested to review a written designation by the Administrator of all individuals who would be present on the premises when the Administrator was not present, however, a designation was not provided for review. 2. In an interview, E1 acknowledged the administrator had not designated, in writing, all individuals who would be present at the nursing supported group home and accountable for the facility when the administrator was not present.

Based on observation and interview, the administrator failed to ensure documentation required to be posted by R9-10-2203(F)(3)(a-e) was posted conspicuously on the premises. Findings include: 1. During a facility tour, the Compliance Officer observed the following: The posted license was not current and had marked renewal date of April 25, 2025; The name, address, and telephone number of The Department's Bureau of Long Term Care Facilities Licensing and Adult Protective Services of the Department of Economic Security were not posted; A notice that a resident may file a complaint with the Department concerning the nursing-supported group home was not posted; The monthly schedule of recreational activities was not posted; and A copy of the current license survey report with information identifying residents redacted, any subsequent reports issued by the Department, and any plan of correction that is in effect; or a notice that the current license survey report with information identifying residents redacted, any subsequent reports issued by the Department, and any plan of correction that is in effect are available for review upon request, was not posted. 2. In an interview, E1 acknowledged the required postings were not conspicuously posted in on the premises. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 3, 2025.

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. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 3, 2024.

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: 1. 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. 2. In an interview, E1 acknowledged a quality management report had not been provided for review. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 3, 2024.

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, or the assigned duties of each nurse and other personnel members who worked each day. 2. In an interview, E1 and acknowledged the provided work schedules did not include all of the required information. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 3, 2024.

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. ARS § 36.411(C)(1) states: 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. ARS § 36-420.01 states: "A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program." R9-10-113(A)(2)(a) states: "A. 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, baseline 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);" Findings include: 1. A review of E2's personnel file revealed E2 had been hired as the administrator and Director of Nursing in July of 2020. However, E2's personnel file did not include the following required documentation: - E2's qualifications, including verification of skills and knowledge applicable to the individual's job duties per R9-10-2206(B)(2); 2. A review of E3's personnel file revealed E3 had been hired as a practical nurse in February of 2025. However, E3's personnel file did not include the following required documentation: - E2's qualifications, including verification of skills and knowledge applicable to the individual's job duties per R9-10-2206(B)(2); - Documentation of E2's orientation and in-service education as required by policies and procedures, to include initial orientation; - Evidence of freedom from infectious tuberculosis per R9-10-113 to include base

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 assessment 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). 2. In an interview, E1 acknowledged the medical records provided for R1 and R2 did not include all required documentation. This is a repeat deficiency from the on-site compliance inspection conducted on April 3, 2024.

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, the posted CLIA waiver had a marked expiration date of October 2024. 3. In an interview, E1 acknowledged a current, valid CLIA waiver for the facility had not been provided for review. E1 reported the facility has applied for a new CLIA waiver.

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. The deficient practice posed a risk if the resident experienced a change in condition due to administration of a duplicative or incompatible 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. This is a repeat deficiency from the on-site compliance inspection conducted on April 3, 2024.

Based on documentation review and interview, the Administrator failed to ensure policies and procedures for medication administration were reviewed and approved by a pharmacist. Findings include: 1. A review of the facility's policies and procedures revealed policies covering medication administration, storage, disposal, and documentation. However, the policies were not reviewed and signed by a pharmacist. 2. In an interview, E1 acknowledged the provided medication administration policies and procedures did not include documentation of review and approval by a pharmacist.

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. Technical assistance was provided for this rule during the on-site compliance inspection conducted on April 3, 2024.

Based on observation and interview, the administrator failed to ensure a posted food menu 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: 1. During an environmental inspection of the facility, the Compliance Officer observed a food menu was not posted in the facility. 2. A review of a May 2025 food menu revealed the menu did not include the items to be served each day, had not been prepared in advance, and included undocumented items such as "leftovers" on multiple days. 3. In an interview, E1 acknowledged the current menu had not been posted and the historical menu did not include the foods served on each day.

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 a disaster plan review was not available for review. 2. In an interview, E1 acknowledged documentation of an annual disaster plan review, to include the items listed in R9-10-2224(A)(4), had not been provided for review. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 3, 2024.

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 facility documentation revealed documentation of disaster drills for employees during the previous twelve months. For the overnight, 8 PM to 6 AM shift, a disaster drill had been conducted on March 11, 2025. However, overnight shift disaster drills conducted in December 2024, September 2024, and June 2024 were not available for review. 2. In an interview, E1 acknowledged the provided documentation of disaster drills conducted on each shift at least once every three months had not included documentation of overnight shift disaster drills conducted at least once every three months. Technical assistance for this rule was provided during the on-site compliance inspection conducted on April 3, 2024.

Based on documentation review, record review, and interview, the administrator failed to ensure a personnel member's skills and knowledge were verified and documented before the personnel member provided physical health services and according to policies and procedures, for two of two sampled personnel. The deficient practice posed a risk if employees were unable to meet the needs of residents. Findings include: 1. A review of the facility's policies and procedures revealed a policy, B-5, titled, "Staffing/Conditions of Employment/Transfers," revised October 26, 2022, which stated, "All qualified applicants will have a minimum of one interview, and at least three references will be completed to verify the applicant has the knowledge, skills, and experience for the position." 2. A review of the facility's electronic policies and procedures revealed job descriptions for each position, to include the required skills and knowledge for each position, were not available for review. 3. A review of the facility's job descriptions, contained in a separate binder, revealed a job description titled, "House Manager", effective January 1, 2012, and revised August 28, 2018. The job description included a detailed description of the job duties and requirements for the position. 4. A review of the facility's job descriptions, contained in a separate binder revealed a job description titled, "Lead Direct Support Professional," effective May 1, 2015 and revised February 20, 2019. The job description included a detailed description of the job duties and requirements for the position. 5. A review of the facility's job descriptions, contained in a separate binder revealed a job description titled, "Direct Support Professional," revised August 26, 2018. The job description included a detailed description of the job duties and requirements for the position. 6. A review of the facility's job descriptions, contained in a separate binder revealed a job description titled, "Staff Nurse," effective January 27, 2014 and revised June 1, 2019. The job description included a detailed description of the job duties and requirements for the position. 7. In an interview, E2 reported E2 was the house manager. 8. A review of E2's personnel record revealed E2 had been hired in March of 2019 as a "DSP" (Direct Support Professional). However, documentation of three completed reference checks to verify E2's skills and knowledge were not provided for review. 9. In an interview, E3 reported E3 was a staff nurse. 10. A review of E3's personnel record revealed E3 had been hired in July of 2023 as a, "LPN." However, this job title did not match any of the provided job descriptions, and was most similar to "Staff Nurse." Additionally, documentation of three completed reference checks to verify E3's skills and knowledge were not provided for review. 11. In an interview, E1 reported personnel files are maintained centrally and are not available to the facility staff. E1 acknowledged documentatio

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

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. 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 fingerprinting requirements of the health professional's regulatory board as a condition of licens

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 April 26, 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 2012, indicating R1's admission date to the facility was on April 26, 2023. 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 2007, indicating R2's admission date to the facility was on April 26, 2023. 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 reported the medical records for residents who had lived at the facility prior to licensure as a Nursing Supported Group Home had not been updated upon licensure to ensure they complied with the requirements of Article 22. E1 acknowledged the medical records provided for R1 and R2 had not included nursing assessments to determine each resident's acuity.

Based on observation and interview, the administrator failed to ensure a vehicle used to provide transportation to a resident contained a working air conditioning system. Findings include: 1. The Compliance Officers observed a facility van used to transport residents. However, the air conditioning system was not operable during the on-site inspection. 2. In an interview, E1 acknowledged the air conditioning system did not appear to be working on the van and reported it would be evaluated immediately and repaired if necessary.

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 acknowledged not all requested policies were immediately provided for review, however, E1 was not certain if policies did exist but were not readily found, or if they would need to be updated.

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 and the facility policy N-9 had not been implemented.

Based on observation, documentation review, and interview, the administrator failed to ensure the nursing-supported group home had battery operated smoke detectors or hard wired smoke detectors with a backup battery that 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: 1. The Compliance Officers observed the facility had hard-wired smoke detectors with a backup-battery mounted on a wall in the garage. However, a tag on the backup battery indicated it had last been inspected on January 27, 2021. 2. The Compliance Officers requested to review the documentation of monthly testing of the backup battery, however, documentation was not provided for review. 3. In an interview, E1 reported not knowing how to check the backup battery. E1 reported there was no current service contract to maintain the alarm system. E1 acknowledged the smoke detector backup battery had not been tested at least once a month.

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. A documentation review of the facility's fire inspection reports revealed the most recently City of Tucson Fire Inspection report available was dated June 26, 2021 and indicated all required corrections had been made by July 7, 2021. 2. In an interview, E1 reported E1 did not know if a current fire inspection had been conducted by the City of Tucson Fire Department. E1 acknowledged a current fire inspection report was not provided for review.