Dignity 1st Home Care Solutions L L C

Based on documentation review and interview, the manager failed to ensure policies and procedures were reviewed and updated at least once every three years. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of facility documentation revealed a policy and procedure manual dated July 11, 2019. However, documentation to indicate the facility's policies and procedures were reviewed and updated at least once every three years was not available for review. 2. In an interview, E1 acknowledged the facility's policies and procedures had not been reviewed at least once every three years.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained of the caregivers and assistant caregiver working each day, including the hours worked. Findings include: 1. The Compliance Officer observed E1 and E2 on the premises and working at 10:45 AM. 2. A review of the facility documentation revealed a staffing schedule dated July 11, 2023 through July 24, 2023. However, the staffing schedule did not include documentation of E1 and E2 working each day, including the hours worked on July 17, 2023 through July 24, 2023. 3. In an interview, E1 acknowledged documentation was not maintained of the caregivers and assistant caregiver working each day, including the hours worked.

Based on documentation review, observation, and interview, the manager failed to ensure a personnel record for an employee or volunteer was maintained throughout the individual's period of providing services in or for the assisted living facility. The deficient practice posed a risk as required information could not be verified for E3. Findings include: 1. A review of Department documentation revealed E3 was the facility manager effective July 18, 2016. 2. The Compliance Officer observed E3's manager's license posted on the wall. 3. The Compliance Officer requested to review E3's personnel record at 11:06 AM. However, E3's personnel record was not provided for review. 4. In an interview, E1 reported E3 took E3's personnel record out of the facility to make changes to the personnel record. 5. In an interview, E1 showed the Compliance Officer the following displayed on E1's mobile phone: -E3's valid fingerprint clearance card; and -E3's ocumentation of current CPR and first aid training. 6. In an interview, E1 acknowledged a personnel record was not maintained throughout E3's period of providing services in or for the assisted living facility.

Based on record review and interview, the manager failed to ensure a residency agreement included the policy and procedure for an assisted living facility to terminate residency, in compliance with A.A.C. R9-10-807(G), for seven of ten residents sampled. Findings include: 1. A review of R1's, R2's, R3's, R5's, R6's, R7's, and R10's medical records revealed residency agreements. The residency agreements stated "...Terminations ...The management will provide the resident or residents' representative thirty (30) day written notice before terminating the Residency Agreement except in the following circumstances: 1. The management will terminate the Residency Agreement without notice if: a. The resident exhibits behavior that is an immediate threat to the health and safety of the resident or other individuals in the assisted living facility b. The residents' medical or health needs require immediate transferred to another healthcare institution c. The residents care and service needs exceed the services the facility is licensed to provide 2. The management will terminate the Residency Agreement after providing fourteen (14) days written notice to a resident or the residents' representative for any of the following reasons: a. Documented failure to pay fees or charges b. Documented non-compliance with the Residency Agreement or Internal Facility Requirements." However, documentation to indicate the policy and procedure for an assisted living facility to terminate residency, in compliance with A.A.C. R9-10-807(G) was not available for review. 2. In an interview, E1 acknowledged R1's, R2's, R3's, R5's, R6's, R7's, and R10's residency agreements did not include the correct provisions for an assisted living facility to terminate residency.