Emmanuel Care Home

Based on record review and interview, the manager accepted and retained an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue, for one of two resident records reviewed. The deficient practice posed a risk as R1's primary condition was not a physical health issue and the facility is not authorized to provide behavioral health services. Findings include: Arizona Administrative Code (A.A.C.) R9-10-101.32. states "Behavioral health issue" means "an individual's condition related to a mental disorder, a personality disorder, substance abuse, or a significant psychological or behavioral response to an identifiable stressor or stressors." 1. A review of R1's medical record revealed a service plan for directed care services, initiated on January 31, 2023, with two updates. The service plan stated, "Medical Diagnosis/Health Problems: Hypertension, Diabetes?, Obsessive Compulsive Disease"; "Physical/Cognitive/Functional Impairments: Unable to perform ADL's without assistance; Unable to manage his own medications"; and "Diagnosis requiring no treatment/or meds only: Anxiety Disorder". The service plan revealed R1 used a 4 wheeled walker. Further review revealed no assistance needed for "Bed Mobility ...Turning ...Transfers ...Wheeling ...Eating ...Grooming ...Oral Care ...Toileting ...". For bathing, the service plan stated R1 needed "set up". For medication, the service plan stated "Hand pills/observe taking". For dressing, the service plan stated, "Complete ...Has the ability to dress (self) but requests assistance". 2. In an interview, E1 and E4 reported R1 did need assisted living services though agreed the service plan did not identify a primary physical health reason as for the services. 3. In an interview, E1 agreed R1 needed assisted living services and behavioral care. E1 did not believe the manager accepted and retained an individual when the primary condition for which the individual needed assisted living services was a behavioral health issue, though understood the documentation did not support this statement.

Based on record review and interview, the manager failed to ensure before or at the time of an individual's acceptance by an assisted living facility, there was a documented residency agreement with the assisted living facility which included the requirements in R9-10-807(D)(1-10) for two of two resident records reviewed. Findings include: 1. A review of R1's medical record revealed a documented residency agreement. However, the residency agreement did not include the following: - The individual's name, - The date of occupancy or expected date of occupancy, and - The manager's signature and date signed. 2. A review of R2's medical record revealed a documented residency agreement. However, the residency agreement did not include the following: - The individual's name, and - The date of occupancy or expected date of occupancy. 3. In an interview, E2 acknowledged R1's and R2's residency agreements did not include all requirements in R9-10-807(D)(1-10).

Based on documentation review, observation, and interview, the manager failed to ensure a facility authorized to provide directed care services had a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area, which alerted employees of the egress of a resident from the facility. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. The Compliance Officer observed when exiting from back door leading to the secured backyard, no alarm sounded to alert employees of the egress of a resident from the facility. Further inspection revealed only one side of the door alert was present on the door. 3. In an interview, E1 acknowledged the back door did not alert employees of the egress of a resident from the facility.