Good Shepherd Assisted Living, LLC

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not implemented. Findings include: 1. Review of facility documentation revealed a policy and procedure titled "Orientation and In Service". This policy stated "New Employee Orientation is required to be completed by all new employees [...] The orientations is completed within 48 hours from the employment start day. The orientation to include but not limited to: [...] -Training for Fall Prevention and Recovery." 2. Review of E3's personnel record revealed no documentation showing that E3 had completed Fall Prevention and Fall Recovery training. 3. In an interview, E1 acknowledged E3's personnel record did not contain documentation that showed the health care institution had administered a training program for all staff regarding fall prevention and fall recovery. This is a repeat deficiency from the on-site compliance inspection conducted on January 3, 2023.

Based on documentation review, record review and interview, the manager failed to ensure an employee provided documentation of freedom from infectious tuberculosis (TB) on or before the date the individual began providing services at or on behalf of the assisted living facility, as specified in R9-10-113, for three of three employees reviewed. The deficient practice posed a potential TB exposure risk to residents. Findings include: 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. Review of the Centers for Disease Control and Prevention website revealed a web page titled "TB Screening and Testing of Health Care Personnel." The web page stated, "If the Mantoux tuberculin skin test (TST) is used to test health care personnel upon hire (preplacement), two-step testing should be used." 3. Review of facility policy and procedure documentation revealed a policy titled "Tuberculosis Testing Policy and Procedure," which stated "The TB test/screening must be BOTH administered AND read prior to the individual being accepted as a resident or as an employee [...]" 4. Review of E1's personnel record revealed a hire date of April 1, 2023. E1's personnel record included one negative TB skin test that was less than 12 months old, however, a second negative TB skin test dated before E1 provided services was not available. 5. Review of E2's personnel record revealed a hire date of April 1, 2024. E2's personnel record included one negative TB skin test that was less than 12 months old, however, a second negative TB skin test dated before E2 provided services was not available. 6. Review of E3's personnel record revealed a hire date of July 1, 2024. E3's personnel record included a document titled "Immunizations Administered" which reported that E3 had been administered one TB skin test before E3's hire date, however, this document did not contain the results of the test, and no other documentation of TB skin tests was available for E3. 7. In an interview, E1 acknowledged E1, E2, and E3 did not provide documentation of freedom from infectious TB as specified in R9-10-113 on or bef

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee included documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1), for two of three personnel records sampled. The deficient practice posed a risk if E1 or E3 were a danger to a vulnerable population. Findings include: A.R.S. \'a7 36-411(C)(1) Owners shall make documented, good faith efforts to: 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. 1. A review of the facility's policies and procedures revealed a policy titled "Applicant and Employee Requirement Policy and Procedure", which stated " Upon being hired by the facility the applicant must: [...] 2 Personal and 2 Professional/Work References (references to be verified by the facility manager)." 2. A review of E1's personnel record revealed a document titled "Character References" which listed the contact information for two personal references and two professional references for E1, however, the spaces on the document for showing that owners had made good faith efforts to 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 were left blank, and no other documentation showing that owners had attempted to contact the references was available. 3. A review of E3's personnel record revealed a document titled "Character References" which listed the contact information for two references for E3, however, the spaces on the document for showing that owners had made good faith efforts to 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 were left blank, and no other documentation showing that owners had attempted to contact the references was available. 4. In an interview, E1 acknowledged documentation of compliance with the requirements in A.R.S. \'a7 36-411(C)(1) for E1 and E3 was not available for review.

Based on record review and interview, the manager failed to ensure a written service plan was updated at least once every three months, for two of two residents reviewed who received directed care services. The deficient practice posed a health and safety risk to the resident if the employees did not know what services the resident needed. Findings include: 1. Review of R1's medical record revealed a current written service plan for directed care services dated April 28, 2024. However, a service plan after April 28, 2024 was not available for review. 2. Review of R2's medical record revealed a current written service plan for directed care services dated April 6, 2024. However, a service plan after April 6, 2024 was not available for review. 3. In an interview, E1 acknowledged R1 and R2 received directed care services and the service plans were not updated at least once every three months.

Based on record review, observation and interview, the manager failed to ensure the caregiver documented the services provided in the resident's medical record, for one of two residents reviewed. The deficient practice posed a risk as services could not be verified as provided against a service plan. Findings include: 1. Review of R2's medical record revealed a current written service plan for directed care services dated April 6, 2024. This service plan stated the following service was needed: "Oral Care: Requires assistance 2X a day" Review of R2's "ADL [Activities of Daily Living] chart" for August 2024 revealed that oral hygiene was documented as provided for "A.M." August 1-11, however documentation showing that oral care assistance was provided a second time each day was not available. 2. In an interview, E1 reported that R2 received assistance in oral care in the morning and at night, and acknowledged that R2's medical record did not include documentation that assistance in oral care was provided two times a day. This is a repeat deficiency from the on-site compliance inspection conducted on January 3, 2023.

Based on observation and interview, the manager failed to ensure that a current toxicology reference guide was available for use by personnel members. Findings include: 1. The Compliance Officer observed the facility's toxicology guide available for use by personnel members was the "Elsevier Toxicology Handbook 3rd Edition". 2. A review of the publisher's website revealed the "Elsevier Toxicology Handbook 4th Edition" was the most recent edition. 3. In an interview, E1 acknowledged that a current toxicology reference guide was not available for use by personnel members.