Magda's Family Home Care LLC

Based on documentation review, record review, and interview, the manager failed to ensure the health care institution developed and administered a training program for all staff regarding fall prevention and fall recovery that included initial training and continued competency training. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. Review of facility documents revealed no documentation of a training program for all staff regarding fall prevention and fall recovery. 2. Review of E1's personnel record revealed E1 worked as a caregiver and had a hire date of February 1, 2021. The personnel record did not include documentation that showed E1 completed fall prevention and fall recovery training. 3. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of February 1, 2021. The personnel record did not include documentation that showed E2 completed fall prevention and fall recovery training. 4. Review of E3's personnel record revealed E3 worked as the manager and had a hire date of November 15, 2020. The personnel record did not include documentation that showed E3 completed fall prevention and fall recovery training. 5. In an interview, E1 and E2 acknowledged documentation was not available that showed E1, E2, and E3 had completed initial training and continued competency training for fall prevention and fall recovery.

Based on documentation review, record review, and interview, the manager failed to ensure policies and procedures were implemented that covered in-service education, for three of three employees reviewed. The deficient practice posed a risk as the caregiver received no organized instruction or information related to physical health services provided to residents. Findings include: 1. Review of the facility's policies and procedures revealed a policy titled "Employee Orientation and Ongoing Training" that stated "....The manager/owner of the facility shall ensure that each caregiver and manager completes a minimum of 6 hours of Supervisory and Personal Care and another 6 hours of Directed/Behavioral care related topics of ongoing training every 12 months from the starting date of employment." 2. Review of E1's personnel record revealed E1 worked as a caregiver and had a hire date of February 1, 2021. The personnel record revealed no documentation of completing in-service education February 1, 2022 to January 31, 2023. 3. Review of E2's personnel record revealed E2 worked as a caregiver and had a hire date of February 1, 2021. The personnel record revealed no documentation of completing in-service education February 1, 2022 to January 31, 2023. 4. Review of E3's personnel record revealed E3 worked as the manager and had a hire date of November 15, 2020. The personnel record revealed no documentation of completing in-service education November 15, 2022 to November 14, 2023. 5. In an interview, E1 and E2 acknowledged E1's, E2's, and E3's personnel records did not include documentation of completing 12 hours of in-service education, as required by the facility's policies and procedures.

Based on record review and interview, the manager failed to ensure a resident had a written service plan signed and dated by the resident or resident's representative and the manager, for two of two residents reviewed. The deficient practice posed a health and safety risk if the required individual did not acknowledge the services that were to be provided. Findings include: 1. Review of R1's medical record revealed written service plans dated December 15, 2022 and June 15, 2023. However, these service plans did not include a signature and date by the resident or resident's representative and the manager. 2. Review of R2's medical record revealed a written service plan dated August 8, 2023. However, this service plan did not include a signature and date by the manager. 3. In an interview, E1 and E2 acknowledged R1's and R2's service plans were not signed and dated by the required individuals.

Based on documentation review, record review, and interview, the manager failed to ensure a resident medical record contained documentation of notification of the resident of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. \'a7 36-406(1)(d), to one of one resident reviewed. The deficient practice posed a potential illness risk to residents. Findings include: 1. A.R.S. \'a7 36-406(1)(d) states "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis. The department shall prescribe the manner by which the institutions and facilities shall document compliance with this subdivision, including documenting residents who refuse to be immunized. The department shall not impose a violation on a licensee for not making a vaccination available if there is a shortage of that vaccination in this state as determined by the director." 2. Review of R1's medical record revealed R1 refused the flu and pneumonia vaccinations December 8, 2020. However, current documentation was not available that showed the flu and pneumonia vaccinations were offered or received. Based on R1's acceptance date, this documentation was required. 3. In an interview, E1 and E2 acknowledged R1's medical record did not include current documentation that showed the flu and pneumonia vaccinations were offered or received.

Based on record review and interview, the manager failed to ensure the facility did not accept or retain a resident who was confined to a bed or chair because of an inability to ambulate even with assistance, unless the facility obtained a written determination from a medical practitioner, every six months, that stated the resident's needs could be met by the facility and the resident's needs were within the facility's scope of services, for one of one resident reviewed who was confined to a bed or chair. The deficient practice posed a risk if the facility was unable to meet a resident's needs. Findings include: 1. Review of R1's medical record revealed a current written service plan dated June 15, 2023. This service plan stated "Non-Ambulatory". 2. Review of R1's medical record revealed a written determination from R1's medical practitioner signed and dated December 8, 2020. However, documentation was not available that stated R1's needs could be met by the facility and R1's needs were within the facility's scope of services, at least once every six months. 3. In an interview, E1 reported R1 was unable to ambulate even with assistance since acceptance and E1 and E2 acknowledged R1's medical practitioner did not provide a written determination at least once every six months.

Based on documentation review and interview, the manager failed to ensure the facility's 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. Review of the facility's policy and procedure revealed a policy titled "Disaster Relocation Plan." A document titled "Annual Disaster Plan Review" revealed the disaster plan was last reviewed April 5, 2021. 2. In an interview, E1 and E2 acknowledged the facility's disaster plan was not reviewed at least once every 12 months.

Based on documentation review and interview, the manager failed to ensure an employee disaster drill 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 the disaster plan. Findings include: 1. Review of the November 2023 personnel schedule revealed one 24 hour shift. 2. Review of the facility's employee disaster drills revealed the most current disaster drill conducted June 1, 2023. No other employee disaster drills were available after June 1, 2023. 3. In an interview, E1 and E2 acknowledged the employee disaster drills were not conducted on each shift at least once every three months.