Legend Ddd Services - Upton Nsgh

Based on record review, documentation review and interview, the administrator failed to ensure that a personnel member's skills and knowledge were verified and documented, for three of four personnel sampled, before the personnel member provided physical health services according to policies and procedures. Findings include: 1 . A review of E2's, E3's and E4's personnel records revealed no documentation for skills and orientation training prior to providing physical health services to residents. 2 . A review of facility documents revealed a Policy and Procedure titled, "Directed Service Personnel Skill Competency" which stated, "Within the first seven days of employment, all direct service personnel will complete a Direct Service Position (DSP) skills competency assessment". 3 . In an interview, E1 acknowledged that E2's, E3's and E4's skills and knowledge were not verified and documented according to policies and procedures.

Based on record review and interview, the Health care institution failed to ensure that there was a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training in fall prevention and fall recovery for three of four employees sampled. Findings include: 1 . A review of E1's, E2's and E3's personnel files revealed no documentation regarding the training for Fall Prevention and Fall Recovery. 2 . In an interview, E1 acknowledged that the Health care institution failed to ensure that there was a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training in fall prevention and fall recovery.

Based on record review and interview, the health care institution's chief administrative officer failed to ensure training and education related to recognizing the signs and symptoms of tuberculosis (TB) was provided annually to individuals employed by the health care institution for four of four employees sampled. The health care institution failed to establish, document, and implement TB infection control activities including annually assessing the health care institution's risk of exposure to infectious TB. The health care institution failed to ensure that the facility was in compliance with recommendations in Tuberculosis Screening, Testing, and Treatment of U.S. Health Care Personnel per R9-10-113.A.1-2. Findings include: 1 . A review of E1's, E2's. E3's and E4's personnel records revealed no documentation of annual Tuberculosis (TB) Signs and Symptoms training. 2 . A review of facility policy revealed a policy 2 . A review of E2's personnel record revealed no documentation for the two step TB test. 4 . A review of E3's and E4's personnel record revealed one TB test completed. A second TB test was not available for review at the time of the inspection. 5 . A review of facility documents revealed no documentation for the annual facility TB risk and assessment. 6 . A review of facility policy titled Personnel Hiring and Training Program, page 177 stated that, "all staff are to have a two step TB test". 7 . In an interview, E1 acknowledged that the health care institution was not in compliance with the TB requirements per R9.10.113.A.1-2.

Based on record review and interview, the administrator failed to ensure that vaccinations for influenza and pneumonia were available to each resident at least once every 12 months and maintained in the resident's medical record for two of two residents reviewed. Findings include: 1 . A review of R1's Person Centered Service Plan revealed the last influenza and pneumonia vaccine offered December 15, 2021. 2 . A review of R2's Person Centered Service Plan revealed the last influenza and pneumonia vaccine offered September 1, 2021. 3 . In an interview, E1 acknowledged that the administrator failed to ensure the vaccinations for influenza and pneumonia vaccines were not made available to each resident at least once every 12 months.