Danville Services of Arizona - Hampton Home

Based on observation and interview, the administrator failed to ensure a fire extinguisher was inaccessible to residents. Findings include: During an environmental tour of the facility, the Compliance Officer observed a fire extinguisher mounted on the wall of the living room. The fire extinguisher was not in an enclosure and was accessible to residents. In an interview, E1 and E2 acknowledged the fire extinguisher was not inaccessible to residents.

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: 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. In an interview, E1 and E2 acknowledged an acuity plan was not provided for review.

Based on documentation review and interview, the administrator failed to ensure documentation of the most recent monitoring of the nursing-supported group home by the Arizona Department of Economic Security (DES) was on the premises. Findings include: During the on-site inspection, the Compliance Officer requested to review the most recent DES monitoring report. However, a DES monitoring report was not available to review. In an interview, E1 reported the facility has not had a DES monitoring inspection since converting to a Nursing Supported Group Home. In an interview, E1 and E2 acknowledged a DES monitoring report was not provided for review.

Based on documentation review and interview, the administrator failed to ensure an organizational chart was maintained on the premises. Findings include: During the on-site inspection, the Compliance Officer requested to review the facility's organizational chart. However, an organizational chart was not provided for review. In an interview, E1 and E2 acknowledged an organizational chart was not maintained on the premises and had not been 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: 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, the assigned duties of each nurse or other personnel member who worked each day, and the actual number of hours worked by each person. In an interview, E1 and E2 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 polices and procedures were established covering the requirements of R9-10-2222.3.a-g. Findings include: A review of the facility's policies and procedures revealed a policy covering all sections of R9-10-2222.3.a-g was not available for review. A review of E3's, E4's, E5's and E6's personnel records revealed training in infection control practices was not available for review. In an interview, E1 and E2 acknowledged an infection control policy covering all required items and training of personnel on this policy had not been provided for review.

Based on observation, documentation review, and interview, the administrator failed to ensure biohazardous medical waste was identified, store, and disposed of according to 18 A.A.C. 13, Article 14 and policies and procedures. R8-13-1401.4 defines “Biohazardous Medical Waste” as follows: “Biohazardous medical waste” is composed of one or more of the following: a. Cultures and stocks: Discarded cultures and stocks generated in the diagnosis, treatment or immunization of a human being or animal or in any research relating to that diagnosis, treatment or immunization, or in the production or testing of biologicals. b. Human blood and blood products: Discarded products and materials that are saturated and/or dripping with human blood or caked with dried human blood, including items that would release blood in a liquid or semi-liquid form if compressed or broken, and items that contain serum, plasma, and other blood components. An item would be considered caked if it could release flakes or particles when handled. c. Human pathological wastes: Discarded organs, tissues, and body parts, including cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid and amniotic fluid, removed during surgery or other medical procedures, including autopsy, obstetrics, or emergency care. Human pathological wastes do not include the head, spinal column, hair, nails, or teeth. d. Medical sharps: Discarded sharps that pose a stick hazard that have come into contact with blood, blood products, or pathological waste. Examples include hypodermic needles; scalpel blades; and needles attached to tubing or syringes. e. Research animal wastes: Animal carcasses, body parts, and bedding of animals that have been infected with agents that produce, or may produce, human infection. f. Tattoo and body modification waste: any waste generated during the course of physically altering a human being, including tattooing, ear piercing, or any other process where a foreign object is used to cut or pierce the skin. g. Trauma scene waste: any crime scene, accident, or trauma clean-up wastes generated by individuals or commercial entities hired to clean crime scenes or accidents, such as sharps and materials that contain human blood and blood products. R8-13-1403.A.4 states: “The following persons are exempt from the requirements of this Article: A household generator residing in a private, public, or semi-public residence who generates biohazardous medical waste in the administration of self care or the agent of the household generator who administers the medical care. This exemption does not apply to the facility in which the person resides if that facility is licensed by the Arizona Department of Health Services.” The Arizona Department of Environmental Quality website, at azdeq.gov/Sharps states: “Disposal Options for Businesses or Facilities that are Licensed by the Department of Health Services: Must have a state registered biohazardous medical waste transp

Based on documentation review and 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. 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, E2 reported the facility has not obtained a fire inspection. In an interview, E1 and E2 acknowledged documentation of a current fire inspection had not been provided for review.

Based on observation and interview, the administrator failed to ensure hot water temperatures were maintained between 95° F and 120° F. Findings include: During an environmental inspection of the facility, the Compliance Officer measured the water temperature at the kitchen sink was 129° F. In an interview, E1 and E2 acknowledged the water temperature had not been maintained between 95° F and 120° F.

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Findings include: A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." A review of R1's and R2's medical records revealed documentation of baseline screening for tuberculosis was unavailable for review. A review of E3’s and E4’s personnel records revealed both employee records contained a single-step TST conducted during their baseline screening. However, a second-step TST as required per R9-10-113.A.1 was not available for review for either employee. A review of facility documentation revealed documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis was unavailable for review. In an interview, E1 and E2 acknowledged the health care institution had not implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f.

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: A review of R1's and R2's medical records revealed the following documents were not provided for review: Documentation of the initial assessment required in R9-10-2207(3) to determine acuity; Documentation of the resident's comprehensive assessment; Individual program plans, including nursing care plans or medical care plans, if applicable; Documentation of physical health services provided to the resident; and Documentation of freedom from infectious tuberculosis required in R9-10-2207(10). In an interview, E1 and E2 acknowledged the medical records provided for R1 and R2 did not include all required documentation.

Based on record review and interview, the administrator failed to ensure personnel members received training on the content and use of the disaster plan, for four of four sampled personnel. Findings include: A review of E3's, E4's, E5's and E6's personnel records revealed documentation of training on the content and use of the disaster plan was not available for review. In an interview, E1 and E2 acknowledged the provided personnel records had not included documentation of training on the content and use of the disaster plan.

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: A review of facility disaster drills revealed drills had been conducted on April 10, 2024, October 16, 2024, November 16, 2024, December 8, 2024, January 18, 2025, and February 8, 2025. However, all drills occurred during the hours of the day shift, and there was a gap of more than three months between April 2024 and October 2024 when the day shift had not documented conducting a disaster drill. In an interview, E1 and E2 acknowledged documentation of disaster drills conducted at least one every three months on each shift was not provided for review.

Based on documentation review, record review, and interview, the health care institution failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery to include initial training and continued competency training for four of four personnel sampled. Findings include: 1. A review of the facility's policies and procedures revealed a Fall Prevention and Fall Recovery policy was not available for review. 2. A review of E3’s, E4's, E5's and E6's personnel records revealed of completed initial training and continued competency training on fall prevention and fall recovery was not available for review. 3. In an interview, E1 and E2 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery.