Illuminated Hearts LLC

Based on record review, documentation review, observation, and interview, the manager of a facility providing directed care services failed to ensure a means of exiting the facility providing access to an outside area alerted employee 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 the license issued by the Department revealed the facility was licensed at the directed care level. 2. A review of documentation revealed R1, and R2 were receiving directed care services. 3. During the environmental inspection the Compliance Officer observed the patio door that led into a courtyard did not have the alert activated to alert the employees of a resident's egress. 4. The Compliance Officer walked over to the left and observed a fence with a gate. The Compliance Officer observed the gate had a lock on it, however, the lock was not locked, it was hanging open. The Compliance Officer was able to open the gate and access the street and the surrounding neighborhood. 5. The Compliance Officer observed on the right side of the yard part of the wall separating their yard from the neighbors was missing. E1 reported the storm from a week ago had blown over the neighbors tree, which then crushed the wall under the weight leaving a large gaping hole in the wall. The wall had a piece of plywood leaning on it, however, it was not secured and did not cover the hole. An individual would be able to walk through the hole into the neighbors yard and out into the street and the surrounding neighborhood. 6. During an interview, E1, acknowledged the alarm on the patio door had been turned off and the patio doors did not alert employees of a resident's egress. E1 and E2 reported the landscaper had been at the facility and must have left the gate unlocked.

Based on documentation review and interview, the manager failed to 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 staffing schedule revealed two shifts: - 7:00 am - 7:00 pm (First Shift), and - 7:00 pm - 7:00 am (Second Shift). 2. A review of documentation titled, "Disaster Drill" revealed the following information: - March 1, 2023, time: 10:00 am (first shift),, - March 1, 2023, time: 6:00 pm (first shift),, - June 2, 2023, time: 10:00 am (first shift),, - June 2, 2023, time: 6:00 pm (first shift),, - September 2, 2023, time 9:00 am (first shift),, - September 2, 2023, time: 6:00 pm (first shift),, - December 1, 2023, time: 11:40 am (first shift), and - December 1, 2023, time: 3:00 pm (first shift). There was no additional documentation or evidence to indicate a disaster drill was conducted on each shift at least once every three months and documented. 3. In an interview, E2, and E3 acknowledged the disaster drills were not conducted on each shift at least once every three months and documented. Technical assistance was provided during the on-site compliance inspection conducted on February 13, 2023.

Based on documentation review, record review, and interview, the healthcare institution failed to implement tuberculosis (TB) infection control activities as specified in R9-10-113. The deficient practice posed a risk as the caregivers received no organized instruction or information related to TB surveillance and posed a TB exposure risk to residents and staff. 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)...c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution; d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis..." 2. A 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. A review of E1's personnel record revealed E1 had a hire date of June 2022. The Compliance Officer observed the following: "Clinical Indication: Tuberculosis screening. Comparison: Radiograph(s) chest, 04/29/2019, Radiology Ltd.". The document indicated on September 30, 2022, E1 had a chest x-ray. No evidence that E1 had a positive test or two-step testing and a baseline screening was documented in E1's personnel records. 4. In an interview, E2, and E3 reported being unaware that E1's medical record did not contain the proper TB testing per R9-10-113. Technical assistance was provided during the on-site compliance inspection conducted on February 13, 2023.