Embrace Hope LLC - N. Ironwood

Based on documentation review and interview, the provider failed to establish, document, and implement policies and procedures for administering an opioid as part of treatment or providing assistance in the self-administration of medication for a prescribed opioid. Findings include: A review of the facility's policies and procedures revealed an Opioid policy covering the requirements found in R9-10-120.F was not available for review. In an interview, E1 and E2 acknowledged the provided policy and procedure manual had not included an Opioid policy covering all requirements found in R9-10-120.F.

Based on observation, documentation review, the administrator failed to designate, in writing, an individual who is present on the premises of the nursing-supported group home and accountable for the nursing-supported group home when the administrator is not present on the nursing-supported group home's premises. Findings include: 1 . Upon arriving at the facility, the Compliance Officer observed the administrator was not present on the nursing-supported group home's premises. The Compliance Officer observed four staff, including a Practical Nurse, and three direct service professionals, were present at the facility. 2. A review of facility documentation revealed documentation of the administrator's designees was not available for review. 3. In an interview, E1 and E2 acknowledged documentation of the administrator's designees was not available for review.

Based on documentation review and interview, the administrator failed to ensure the facility's policies and procedures were reviewed at least once every three years. Findings include: A review of the facility's policies and procedures revealed documentation of an overall review of the policy manual by the administrator was not available for review. In an interview, E1 and E2 acknowledged the provided policy manual had not included documentation of the administrator's review at least once every three years.

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 if employees were not able to meet the needs of residents. Arizona Revised Statutes (ARS) § 36-406 states: ARS § 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 a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after 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 licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section. 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. 2. Verify the current status of a person's fingerprint clearance card. 3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee. 4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee. 5. Beginning March 31, 2025, annu

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: 1. A review of R1's and R2's medical records revealed the following documents were not provided for review: a. Documentation of the initial assessment required in R9-10-2207(3) to include a determination of each resident's acuity. each record included an initial assessment form, however, the form did not include the signature of the registered nurse who conducted the assessment and did not include a determination of each resident's acuity; b. The medical history and physical examination required in R9-10-2215(A)(2). Each resident had primary care physician examinations at least annually, however, a history and physical dated more than 30 days prior to or within 10 days after admission for each resident was not available for review; c. Documentation of the resident's comprehensive assessment required in R9-10-2214.A; d. Individual program plans, including nursing care plans or medical care plans, if applicable, as required in R9-10-2214.B; e. Current medication orders for all medications administered to each resident. Each resident had recent, signed orders for medications, however, these orders did not match the medications documented to have been administered to each resident on their Medication Administration Records; f. Documentation of physical health services provided to the resident. Both residents required personal care services such as bathing, toileting, and grooming, and daily progress notes captured some of these activities, however, not all provided services had been documented each day, and the reviewed progress notes were entered by a nurse who had not provided all services at the facility; g. Documentation of freedom from infectious tuberculosis required in R9-10-2207(10). Both residents had a negative skin test, however, the baseline screening questionnaire required in R9-10-113.A.2.a was not available for review. 2. In an interview, E1 and E2 acknowledged the medical records provided for R1 and R2 did not include all required documentation.

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 and E2 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 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 respond in an emergency. Findings include: 1. A review of facility documentation revealed documentation of a disaster drill for employees conducted once on each shift every three months was not available for review. 2. In an interview, E1 and E2 acknowledged documentation of disaster drills was not available for review.

Based on documentation review and interview, the Administrator failed to 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 respond in an emergency. Findings include: 1. A review of facility documentation revealed documentation of an evacuation drill for employees conducted once on each shift every three months was not available for review. 2. In an interview, E1 and E2 acknowledged documentation of evacuation drills was not available for review.

Based on documentation review and interview, the administrator failed to ensure an evacuation drill for residents was conducted at least once each year on each shift and documented. The deficient practice posed a risk if residents were unable to evacuate safely in an emergency. Findings include: A review of facility evacuation drills for residents revealed no documented evacuation drills were available for review. In an interview, E1 and E2 acknowledged documentation of annual resident evacuation drills on each shift had not been provided for review.

Based on observation an interview, the administrator failed to ensure smoke detectors were installed in each bedroom, hallway that adjoins a bedroom, storage room, laundry room, attached garage, and room or hallway adjacent to the kitchen, and other places recommended by the manufacturer. Findings include: During an environmental tour of the facility, the Compliance Officer observed a laundry room. However, the laundry room did not contain a smoke detector. During an environmental tour of the facility, the Compliance Officer observed an attached garage. However, the attached garage did not contain a smoke detector. In an interview, E1 and E2 acknowledged smoke detectors had not been installed in the laundry room or attached garage.

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 127° F. In an interview, E1 acknowledged the water temperature had not been maintained between 95° F and 120° F.