Family Touch

Based on documentation review, record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411 for one of two personnel sampled. The deficient practice posed a risk if E2 was a danger to a vulnerable population. Findings include: 1. A.R.S. \'a7 36-411 states, "Owners 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." 2. A review of E2's employee application revealed documentation of professional references, however no documentation of the facility's contact of E2's references was available for Compliance Officer review. 3. A review of E2's personnel record revealed documentation of a fingerprint clearance card (FPCC). The FPCC was dated prior to E2's hire date of record, however no documentation of FPCC verification was available for Compliance Officer review. 4. In an interview, E1 acknowledged that E2's references and FPCC card were not verified, and the governing authority failed to ensure compliance with A.R.S. \'a7 36-411.

Based on documentation review and interview, the manager failed to ensure that a plan was documented and implemented for an ongoing quality management program. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Quality Management Program Including Incident Reports." The policy stated, "Facility personnel will document and evaluate incidents at the facility to ensure quality services are provided. A copy of each filled out form regarding the incident, accident, emergency, unusual occurrence, or event that put the resident in danger ... will be placed in the QOS Folder and the Quality of Service Monthly Recording Form." 2. During the on-site compliance inspection, the Compliance Officer requested the facility's quality management documentation at 9:30 AM. However, no documentation was provided for Compliance Officer review. 3. In an interview, E1 reported the facility's quality management documentation was in compliance but was stored at E1's home rather than at the facility. E1 acknowledged a plan was not documented or implemented for an ongoing quality management program at the time of inspection.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver's skills and knowledge were verified and documented before the caregiver provided health services for one of two personnel sampled. The deficient practice posed a risk if a personnel member was unable to meet a resident's needs. Findings include; 1. A review of the facility's policies and procedures revealed a policy titled, "Employee and Volunteer Qualifications." The policy stated, "Employment requirements: ... Verification of skills and knowledge documentation before providing any assisted living services to the residents." 2. A review of E2's personnel record revealed no documentation of verification of E2's skills and knowledge prior to providing health services. 3. In an interview, E1 reported E2 was scheduled to work and provide services in the month of August 2024. E1 acknowledged verification of skills and knowledge was not documented in E2's personnel record before E2 provided health services.

Based on documentation review and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last day on the documentation of the caregivers working each day, and included the hours worked by each. Findings include: 1. During the on-site compliance inspection, the Compliance Officer requested the facility's staff schedule at 9:30 AM. However, no documentation was provided for Compliance Officer review. 2. In an interview, E1 reported the employee schedule was stored digitally, and E1 was unable to provide the schedule during the on-site inspection. E1 acknowledged documentation was not maintained for at least 12 months after the last day on the documentation of the caregivers working each day.

Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver received orientation that was specific to the duties to be performed by the caregiver before providing assisted living services to a resident. The deficient practice posed a risk if the employees were unable to meet residents' needs. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled, "Employee and Volunteer Qualifications." The policy stated, "Employment requirements: ... Employee orientation before providing services to the residents." 2. A review of E2's personnel record revealed no documentation of E2's orientation prior to providing health services. 3. In an interview, E1 reported E2 was scheduled to work, and provide services in the month of August 2024. E1 acknowledged E2's orientation was not documented in E2's personnel record before E2 provided health services.

Based on record review and interview, the manager failed to ensure that a resident's medical record contained documentation of assisted living services provided to the resident for two of two residents sampled. The deficient practice posed a risk if services provided could not be verified. Findings include: 1. A review of R1's service plan (dated July 7, 2024) revealed R1 received the following assisted living services: - Shower, twice a week; - Bed bath, five times a week and as needed (PRN); - Total assist with dressing; - Total assist with grooming, twice a day (BID); - Nail care, twice a week; - Incontinence care; - Total assist with eating; - Total assist with transfers; - Encouragement to drink fluids to maintain hydration; - Encouragement to eat meals and snacks; - Cognitive stimulation and activities to maximize functioning; - Safety checks, every two hours (q2h); and - Medication administration. 2. A review of R2's service plan (dated January 4, 2024) revealed R2 received the following assisted living services: - Shower, twice a week; - Bed bath, five times a week and PRN; - Partial assist with dressing; - Partial assist with grooming, BID; - Nail care, twice a week; - Shaving, twice a week and PRN; - Incontinence checks, three times a day (TID) and PRN; - Partial assistance with transfers; - Encouragement to drink fluids to maintain hydration; and - Medication administration. 3. A review of R1's and R2's medical records revealed no documentation of the assisted living services provided to the residents. 4. In an interview, E1 reported documentation of services was available, but not stored at the facility. However, no documentation was provided for Compliance Officer review. E1 acknowledged R1's and R2's medical records did not contain documentation of assisted living services provided to the residents.

Based on record review, observation, and interview, the manager failed to ensure that a resident's medical record contained a medication order from a medical practitioner for each medication that was administered to the resident for two of two residents sampled. The deficient practice posed a risk as medication administered could not be verified against a medication order. Findings include: 1. A review of R1's and R2's medical records revealed R1 and R2 received medication administration. 2. A review of R1's medical record revealed unsigned medication orders (dated July 11, 2024) for: - Nystatin Cream 100000 Unit/grams (GM), apply dime sized amount topically to rash areas as needed (PRN) twice a day (BID); - Senna 8.6-50 milligrams (mg), 2 tablets by mouth (po) daily (qd); - Cozaar 25 mg, 1 tablet po qd; - Metformin HCl ER 500 mg, 1 tablet po qd; and - Allopurinol 100 mg, 1 table po qd. 3. The Compliance Officer observed the following medications stored by the facility for administration to R1: - Nystatin Cream 100000 Unit/GM; - Senna 8.6-50 mg; - Cozaar 25 mg; - Metformin HCl ER 500 mg; and - Allopurinol 100 mg. 4. A review of R2's medical record did not contain medication orders for: - Amlodipine Besylate 10 mg; 1 tab po qd; and - Ciclopirox 0.77% Cream 90 mg, apply topically to the affected area BID. 5. A review of R2's medical record revealed an unsigned order dated July 31, 2024 for Trazodone 50 mg, 1 tablet po at bedtime (qhs). 6. The Compliance Officer observed the following medications stored by the facility for administration to R2: - Amlodipine Besylate 10 mg; - Ciclopirox 0.77% Cream 90 mg; and - Trazodone 50 mg. 7. In an interview, E1 reported R1 and R2 had been administered the aforementioned medications as directed. E1 acknowledged R1's and R2's medical records did not contain a medication order from a medical practitioner for each medication that was administered to the residents.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of two residents sampled. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. A review of R1's service plan (dated July 7, 2024) revealed R1 received directed care services and was non-ambulatory. 2. During the on-site compliance inspection, the Compliance Officer requested R1's determination of continued residency at 9:30 AM. However, no documentation was provided for Compliance Officer review. 3. In an interview, E1 reported R1's determination documentation was in compliance but was stored at E1's home rather than at the facility. E1 acknowledged that R1's medical record did not contain a written determination from a medical practitioner, updated every six months at the time of inspection.

Based on observation and interview, the manager failed to ensure that a bell, intercom, or other mechanical means to alert employees was available in a bedroom being used by a resident receiving directed care services for one of one resident's sampled. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed R1's room which did not contain a bell or mechanical means to alert employees. Additionally, the Compliance Officer observed other directed care resident's rooms that did not contain a bell throughout the environmental inspection. 2. During an interview, E1 reported R1's bell had broken recently, and E1 had not replaced it at the time of inspection. E1 acknowledged that a bell, intercom, or other mechanical means to alert employees was available in a bedroom being used by a resident receiving directed care services.

Based on record review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A review of R1's medical record revealed R1 received directed care services. 2. During an environmental tour of the facility, the Compliance Officer observed the front door was equipped with an alarm to alert employees of egress; however the alarm was not turned on at the time of inspection. 3. The Compliance Officer observed the back door to the patio was unlocked and did not contain a way to alert employees of egress from the facility. 4. In an interview, E1 acknowledged that the facility provided directed care services, and did not contain a way to control or alert employees of the egress of a resident from the facility on all exits.

Based on record review, documentation review, and interview, the manager failed to ensure that a resident's medical record contained documentation of medication administered to the resident for two of two residents sampled. The deficient practice posed a risk as medication could not be verified as administered against a medication order. Findings include: 1. A review of R1's and R2's medical record revealed R1 and R2 received medication administration. 2. During the on-site compliance inspection, the Compliance Officer requested R1's and R2's medication administration records (MAR) at 9:30 AM. However, no documentation was provided for Compliance Officer review. 3. A review of the facility's policies and procedures revealed a policy titled, "Medications Including Opioids and Narcotics: Part III - Medication Administration, Records and Monitoring." The Policy stated, "10. The trained caregiver will initial in the MAR and include the date and time the medicine was given to the resident and the medications that were taken." 4. In an interview, E1 reported R1's and R2's MAR was in compliance but was stored at E1's home rather than at the facility. E1 acknowledged R1's and R2's medical records did not contain documentation of medication administered to R1 and R2.

Based on documentation review and interview, the manager 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. During the on-site compliance inspection, the Compliance Officer requested the facility's disaster drill documentation at 9:30 AM. However, no documentation was provided for Compliance Officer review. 2. In an interview, E1 reported the disaster drill documentation was in compliance but was stored at E1's home rather than at the facility. E1 acknowledged documentation was not available that showed a disaster drill for employees was conducted on each shift at least once every three months and documented.

Based on documentation review and interview, the manager failed to ensure that documentation of each evacuation drill was created and maintained for at least 12 months after the date of the drill. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. During the on-site compliance inspection, the Compliance Officer requested the facility's evacuation drill documentation. However, no documentation was provided for Compliance Officer review. 2. In an interview, E1 reported an evacuation drill for employees and residents was conducted earlier in 2024, but no documentation of the drill was stored at E1's home rather than at the facility. E1 acknowledged documentation was not available that showed an evacuation drill was conducted every six months.

Based on observation and interview, the manager failed to ensure that toxic materials stored by the assisted living facility were maintained in a locked area and inaccessible to residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officer observed the following toxic materials stored unlocked in a cabinet below the sink of the kitchen: - Sprayway Glass Cleaner; and - Lysol All Purpose Cleaner. The cabinet was equipped with a lock, however the lock was not in use at the time of inspection. 2. During an environmental tour of the facility, the Compliance Officer observed the following toxic materials stored on the counter of a shared resident bathroom: - Lysol Disinfectant Spray; and - Febreze Air Mist. 3. During an environmental tour of the facility, the Compliance Officer observed the following toxic materials stored unlocked in a cabinet below the sink of a shared resident bathroom: - Sprayway Glass Cleaner; - Clorox Disinfecting Wipes; - Lysol Disinfecting Spray; - Lysol Toilet Bowl Cleaner; and - Clorox Toilet Bowl Cleaner with Bleach. The cabinet was equipped with a lock, however the lock was not in use at the time of inspection. 4. In an interview, E1 acknowledged the toxic materials store by the facility were not maintained in a locked area and inaccessible to residents.