Home of Hephzibah - Zion Compassion

Based on observation and interview, the administrator did not ensure electrical outlets on the premises were safe, covered with a faceplate, and installed in accordance with the requirements of the of the local jurisdiction. Findings include: 1 . During an environmental inspection, the Compliance Officer observed an electrical outlet on the exterior of the second building on the premises appeared to be missing the faceplate. 2 . During an interview, E5 acknowledged an electrical outlet on the premises was not safe and covered with a faceplate.

Based on record review and interview, the administrator did not ensure a resident provided evidence of freedom from infectious tuberculosis (TB) before or within seven calendar days after the resident's admission and as specified in R9-10-113, for two of two residents sampled. 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. A review of R1's and R2's medical record revealed evidence of R1's and R2's freedom from infectious TB was not available for review. 3. In an interview, E1 acknowledged completed evidence of R1's and R2's freedom from infectious TB was not available for review.

Based on documentation review, record review, and interview, the administrator failed to ensure that a personnel member or an employee provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113 for four of four personnel sampled. The deficient practice posed a potential illness 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. A review of the Centers for Disease Control and Prevention website revealed a web page titled, "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin Test) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E1's personnel record revealed a hire date of August 2020. E1's personnel record included a negative TST. However, no second TST and no questionnaire assessing E1's risks of prior exposure to infectious tuberculosis and determining if the E1 had signs or symptoms of TB was available for review. 4. A review of E2's personnel record revealed a hire date of October 2020. E2's personnel record included 2 negative TST. However, no questionnaire which assessed E2's risks of prior exposure to infectious tuberculosis and determined if the E2 had signs or symptoms of TB was available for review. 5. A review of E3's personnel record revealed a hire date of January 2021. E3's personnel record included a positive TST and documentation from a medical practitioner which verified E3's freedom from infectious TB. However, no questionnaire which assessed E3's risks of prior exposure to infectious tuberculosis and determined if the E3 had signs or symptoms of TB was available for review. 6. A review of E4's personnel record revealed a hire date of September 2024. E4's personnel record revealed no evidence of E4's freedom from infectious TB was available for review. 7.

Based on documentation review and interview, the administrator did not ensure the disaster plan was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees. Findings include: 1. A review of facility documentation revealed a disaster plan. However, no documentation of a disaster plan review was available for Compliance Officer review. 2. In an interview, E1 acknowledged the facility's disaster plan was not reviewed at least once every 12 months.

Based on documentation review and interview, the administrator did not 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 implement a disaster plan. Findings include: 1. A review of the facility's personnel schedule revealed the facility operated with two staff shifts. 2. A review of the facility's disaster drill documentation revealed a disaster drill conducted on the following dates and shifts: - October 7, 2022 at 19:00. However, no documentation of disaster drills having been conducted after October 7, 2022 were available for review. 3. In an interview, E5 acknowledged a disaster drill for employees was not conducted at least once every three months on each shift and documented.

Based on documentation review and interview, the administrator did not 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 implement an evacuation plan. Findings include: 1. A review of the facility's personnel schedule revealed the facility operated with two staff shifts. 2. A review of the facility's evacuation drill documentation revealed an evacuation drill conducted on the following date and shift: - October 7, 2022 at 19:00. However, no documentation of an evacuation drill having been conducted after October 7, 2022 was available for review. 3. In an interview, E5 acknowledged an evacuation drill for employees was not conducted at least once every three months on each shift and documented.

Based on documentation review and interview, the administrator did not ensure an evacuation drill for residents was conducted at least once each year on each shift and documented. Findings include: 1 . A review of facility documentation revealed an evacuation drill dated October 7, 2022 conducted at 19:00. However, no documentation of an evacuation drill being conducted each year was available for review. 2 . In an interview, E5 acknowledged an evacuation drill for residents was not conducted at least once each year on each shift and documented.

Based on observation and interview, the licensee did not ensure the premises, it's structures, and furnishings are in sufficiently good repair that no object, equipment, or condition present constitutes a hazard. Findings include: 1. During an environmental inspection, the Compliance Officers observed the following items needing repair: Door frames and doors in the facility transitioning from resident bedrooms and bathrooms appeared to be damaged, missing paint, and contain exposed splintered wood; The walls leading to a closet in a resident bedroom appeared damaged, missing sheetrock, and contained exposed metal corner joints; and The floor behind a the toilet in a resident bathroom appeared to be damaged and contain accessible rust. 2. During an interview, E5 acknowledged the premises, it's structures, and furnishings were not in good repair that no object, equipment, or condition presented constituted a hazard.