Embrace Hope LLC - E. Cloverfield

Based on document review and interview the assisted living facility failed to maintain a copy of the document provided to the emergency responder and documentation of the actions required by subsection B of this section for a period of two years after the date of the emergency. Findings include: 1 . In an interview E1 acknowledged that R1 had been transported to the hospital by emergency responders, however there was not a copy of the emergency responders form in R1's medical file, for review. 2 . In an exit interview the findings were reviewed with E1 and no further information was provided.

Based on document review and interview, the administrator failed to ensure that a training program for all staff regarding fall prevention and fall recovery was conducted. Findings include: 1 . A review of facility documents revealed a policy and procedure for Fall Prevention and Fall Recovery training and a training program, however the Compliance Officer did not find evidence of E2, E3, and E4 completing the required training, for fall prevention and fall recovery. 2 . In an interview, E1 reported that the training certificates were not at the facility and that E1 did not have access to the training records, at the time of inspection.

Based on record review, document review and interview, the administrator failed to ensure that employees provided evidence of freedom from tuberculosis upon hire, annually obtaining documentation of an individual's freedom from symptoms of infectious tuberculosis, provide annual training and education related to recognizing signs and symptoms or tuberculosis to individuals employed and annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 1 . A review of E2's, E3's employee records revealed one test documented of the individual's freedom from symptoms of infectious tuberculosis, signed by a medical practitioner, occupational health provider, as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101. 2 . A review of E4's employee record revealed no documented test of freedom from symptoms of infectious tuberculosis as defined in A.A.C. R9-6-801, or local health agency, as defined in A.A.C. R9-6-101. 4 . A review of facility documents revealed no annual risk assessment for the health care institution, for review by the Compliance Officer. 5 . A review of E2's, E3's and E4's revealed no annual training on the signs and symptoms of tuberculosis. 6 . In an interview, E1 acknowledged that administrator failed to ensure the facility was following the requirements for R9-10-113.A.1-2. Tuberculosis Screening.

Based on record review and interview, the administrator failed to ensure that before admission or 10 working days after admission, a medical history and physical examination was completed on a resident by a medical practitioner, physician or registered nurse. Findings include: 1 . A review of R1's medical record revealed no physical examination, prior to admission or within 10 working days after admission, for the Compliance Officer to review. 2 . In an interview, E1 acknowledged that there was no medical examination for R1 available, at the time of inspection.

Based on record review and interview, the administrator failed to ensure that a resident provided evidence of freedom from infectious tuberculosis before or within seven calendar days after the resident's admission and as specified in R9-10-113. Findings include: 1 . A review of R1's record revealed no evidence of freedom from tuberculosis upon admission or within seven calendar days after admission. Based on R1's date of admission, this documentation was required. 2 . In an interview, E1 acknowledged that R1 did not have a tuberculosis test available for review at the time of inspection.

Based on document review, the administrator failed to ensure that 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 . The Compliance Officer reviewed facility documents and found no disaster drills for employees were conducted per the rule. 2 . In an interview, E1 reported that there were no disaster drills conducted for employees on each shift at least once every three months.

Based on document review and interview, the administrator failed to ensure that evacuation drills were conducted and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1 . A review of facility documents revealed no evacuation drills for the Compliance Officer to review, at the time of inspection. 2 . In an interview, E1 acknowledged that there were no evacuation drills conducted and documented.

Based on document review and interview, the administrator failed to ensure that a pest control program was implemented and documented. Findings include: 1 . A review of facility documents, by the Compliance Officer, revealed no pest control policy or documentation. 2 . In an interview, E1 acknowledged that there was not a pest control policy for the facility.

Based on observation and interview, the administrator failed to ensure the premises and its structures were in sufficiently good repair. Findings include: 1 . During an environmental tour of the facility, the Compliance Officer observed the following items to not be in good repair or clean: Holes in two different walls in a resident's room Walls in the hallway scuffed up with black marks A Corner of a wall in the hallway with exposed flashing and peeling paint. 2 . In an interview, E1 acknowledged that the premises were not in sufficiently good repair.

Based on observation, 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, habilitation services, or behavioral care, for two of two personnel members sampled. The deficient practice posed a risk if a personnel member did not have the skills and knowledge necessary to meet a resident's needs. Findings include: 1. During the environmental inspection of the facility, the Compliance Officers observed E2 and E3 providing physical health services. 2. A review of E2's personnel record revealed E2 was hired as a nurse. However, evidence of documentation of verification of E2's skills and knowledge was unavailable for review. 3. A review of E3's personnel record revealed E3 was hired as a caregiver. However, evidence of documentation of verification of E3's skills and knowledge was unavailable for review. 4. In an interview, E1 reported neither E2's nor E3's skills and knowledge were verified and documented prior to providing physical health services, habilitation services, or behavioral care to residents.

Based on record review and interview, the administrator failed to ensure the personnel record included documentation of training in preventing, recognizing and reporting abuse or neglect for two of two personnel sampled. The deficient practice posed a risk to the health and safety of residents. Findings include: 1. A review of E2's and E3's personnel record revealed evidence of documentation of training in preventing, recognizing and reporting abuse or neglect was unavailable for review. 2. In an interview E1 agreed the personnel records for E2 and E3 did not contain evidence of documentation of training in preventing, recognizing and reporting abuse or neglect as required.