Dreamcare Prescott

Based on documentation review, record review, and interview, the administrator failed to ensure that a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's admission and as specified in R9-10-113, for two of two residents sampled. The deficient practice posed a TB exposure risk to residents. 1. R9-10-113.A states, "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, 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)..." 2. A review of R1's (admitted January 2022) medical record revealed documentation of R1's freedom from infectious TB. However, no assessment of risks of prior exposure to TB was available for review. 3. A review of R2's (admitted March 2022) medical record revealed documentation of R2's freedom from infectious TB. However, no assessment of risks of prior exposure to TB was available for review. 4. In an interview, E4 acknowledged R1 and R2 did not provide evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after R1's and R2's admission.

Based on record review, documentation review, and interview, the health care institution's chief administrative officer did not ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for three of three personnel sampled. The health care institution did not establish, document, and implement tuberculosis (TB) infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The deficient practice posed a potential illness risk to residents and staff. Findings include: 1. A review of E1's, E2’s, and E3’s personnel record revealed no documentation of training and education related to the signs and symptoms of TB provided annually was available for review. 2. A review of facility documentation revealed no assessment of the health care institution’s risk of exposure to infectious TB was available for review. 3. In an interview, E2 acknowledged E1's, E2's, and E3's personnel record did not include documentation of annual training on recognizing the signs and symptoms of TB. E1 acknowledged no assessment of the health care institution’s risk of exposure to infectious TB was documented.

Based on documentation review and interview, the administrator did not ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed no documentation of disaster drills being conducted was available for review. 2. In an interview, E4 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the administrator did not ensure an evacuation drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility’s documentation revealed no documentation of employee evacuations drills being conducted was available for review. 2. In an interview, E4 acknowledged an evacuation drill for employees was not conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the administrator did to ensure an evacuation drill for residents was conducted at least once each year on each shift and documented. Findings include: 1. A review of facility documentation revealed documentation of evacuation drills for residents conducted was not available for review. 2. In an interview, E4 acknowledged an evacuation drill for residents was not conducted at least once each year on each shift and documented.

Based on observation and interview, the administrator did not ensure the premises, it's structures, and furnishings were in sufficiently good repair that no object, equipment, or condition present constitutes a hazard. Findings include: 1. During an environmental inspection, the Compliance Officers observed the following items needing repair: The flooring in the dining room and kitchen appeared to be separated causing a trip hazard. 2. During an interview, E4 acknowledged the premises, it's structures, and furnishings were not in good repair that no object, equipment, or condition presented constituted a hazard.