Holy Family Assisted Living

Based on documentation review, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of evidence of freedom from infectious tuberculosis (TB), as specified in R9-10-113.A.2.a.i-ii, for one of two personnel sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. R9-10-113.A states "A. 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. A review of E4’s personnel record revealed documentation of a risk assessment of prior exposure to infectious TB and a determination of whether E4 had signs or symptoms of TB. However, this documentation was not completed on or before the date the individual began providing services at or on behalf of the assisted living facility, and based on E4’s hire date, this documentation was required. 3. In an interview, E2 acknowledged that E4’s personnel record did not contain the documentation required in R9-10-113.A.2.a.i-ii, completed on or before the date the individual began providing services at or on behalf of the assisted living facility, and based on E4’s hire date, this documentation was required. 5. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113.A.2.a.i-ii, for two of two residents sampled. The deficient practice posed a TB exposure risk to residents and the Department was unable to determine substantial compliance as the documentation was not provided during the inspection. Findings include: 1. R9-10-113.A states "A. 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. A review of R1’s and R2’s medical records revealed documentation of a risk assessment of prior exposure to infectious TB or a determination of whether the residents had signs or symptoms of TB, signed by a registered nurse. However, this documentation was not completed before or within seven calendar days after the residents’ dates of occupancy, and based on R1’s and R2’s admission dates, this documentation was required. 3. In an interview, E2 acknowledged that R1’s and R2’s medical records did not contain documentation required in R9-10-113.A.2.a.i-ii completed before or within seven calendar days after the residents’ dates of occupancy, and that, based on R1’s and R2’s admission dates, this documentation was required. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on record review and interview, the manager failed to ensure that a resident accepted by the assisted living facility submitted documentation signed by a medical practitioner or a registered nurse that stated whether the individual required continuous medical services, continuous or intermittent nursing services, or restraints for two 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 medical record revealed documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints; however, this documentation was not completed within 90 calendar days before the individual was accepted by the assisted living facility. 2. A review of R2's medical record revealed no documentation that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. Based on R2's acceptance date, this document was required. 3. In an interview, E2 acknowledged R1's documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints was not completed within 90 calendar days before the individual was accepted by an assisted living facility, and R2's medical record did not contain documentation signed by a medical practitioner or a registered nurse that stated whether the resident required continuous medical services, continuous or intermittent nursing services, or restraints. 4. In an exit interview, the findings were reviewed with E2, and no additional information was provided.

Based on documentation review, record review, and interview, the manager failed to ensure that staff obtained a certificate of completion, as specified in R9-10-126, which requires staff to complete a minimum of eight hours of initial memory care services training within the first 30 days of hire or provide a copy of a qualifying certificate of completion. The deficient practice posed a risk if the individuals were not qualified to provide the required memory care services. Findings include: 1. A review of Department records revealed the facility is licensed at the Directed Care Level. 2. A review of E1’s, E2’s, E3’s, and E4’s employee records revealed no certificate of completion for initial memory care services training, and based on their dates of hire, this documentation was required. 3. In an exit interview, the findings were discussed with E2, and no other information was provided. Technical assistance was provided on this Rule during the initial inspection conducted on July 23, 2025.