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Source: AZ State Licensing Agency
The following deficiencies were found during the on-site compliance inspection conducted on May 9, 2024:
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 and some days at 7:00 am to 2:00 pm (First Shift), and - 7:00 pm - 7:00 am (Second Shift). 2. A review of documentation titled, "Disaster Drill" revealed the following information: - June 5, 2023, time 9:00 am (first shift), - June 5, 2023, time 1800 (6:00 pm) (first shift), - September 6, 2023, time ?, shift ?, - September 6, 2023 time 1800 (6:00 pm) (first shift), - December 24, 2023, time 10:00 am (first shift), - December 24, 2023, time 5:45 pm (first shift), - March 26, 2024, time 9:00 am (first shift), and - March 26, 2024, 5:45 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, E1, and E2 acknowledged the disaster drills for employees were not done on each shift. Technical assistance was provided during the on-site compliance inspection conducted on April 17, 2023.
Based on documentation review, record review, and interview, the manager failed to ensure the health care institution administered a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy and procedure titled, "Fall Prevention and Reduction in Assisted Living and Personal Care"." This policy contained information on fall prevention and fall recovery with a training program. 2. A review of E1, E2 and E3's personnel records revealed documentation of an initial training however, E1, and E3 did not have documentation of annual fall prevention and fall recovery training in their personal record 3. In an interview, E1, acknowledged E1, and E3's personal records did not have documentation they reviewed or received annual fall prevention and fall recovery training.
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