Maria Apalategui Afc

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 for fall prevention and fall recovery. 2. A review of E1, E2, and E3's personnel records revealed initial training for E1, E2, and E3, however, no documentation was provided to show annual training. 3. In an interview, E1, acknowledged E1, E2, and E3 did not have documentation of annual training for fall prevention and fall recovery. Technical assistance was provided during the on-site compliance inspection conducted on June 27, 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 for three of three employees sampled. Findings include: 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: ...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. 1. A review of E1, E2, and E3's personnel records revealed no documentation of TB infection control activities to include annual training and education related to recognizing signs and symptoms of TB. No other documentation was available for review during the compliance inspection. 2. In an interview, E1 acknowledged the personnel records provided for E1, E2, and E3 did not include current documentation of annual TB education. Technical assistance was provided during the on-site compliance inspection conducted on June 27, 2023.

Based on documentation review and interview, the manager failed to ensure that the health care institution established, documented, and implemented tuberculosis infection control activities that included annually assessing the health care institution's risk of exposure to infectious tuberculosis. Findings include: 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: ... d. Annually assessing the health care institution's risk of exposure to infectious tuberculosis..." 1. A review of facility documentation revealed an annual assessment of the health care institution's risk of exposure to infectious tuberculosis was not available for review. 2. In an interview, E1 acknowledged the required documentation was not available for review. Technical assistance was provided during the on-site compliance inspection conducted on June 27, 2023.

Based on documentation reviewed and interview, the manager failed to establish and document a policy and procedure as part of the policies and procedure required in R9-10-803(C)(1)(h) to ensure the manager or a caregiver was available as a back-up to provide assisted living services to a resident if the manager or a caregiver assigned to work was not available or not able to provide the required assisted living services. Findings include: 1. A review of the facility's policy and procedures manual revealed the facility had not established, documented, and implemented as needed a policy and procedure regarding backup staffing to provide assisted living services to a resident. 2. The Compliance officer asked E1 for a copy of the staffing schedules. 3. A review of a calendar E1 provided to the Compliance Officer revealed a yearly calendar with just E1's name. No documentation of a backup manager or caregiver was available for review. 4. In an interview, E1 acknowledged the facility had not established, documented, and implemented a policy that covered back-up staffing, and no backup manager or caregiver was on the staffing schedule. Technical assistance was provided during the on-site compliance inspection conducted on May 25, 2022.

Based on record review, documentation review, observation, and interview, the manager failed to ensure a resident had a written service plan completed no later than 14 calendar days after the resident's date of acceptance for one of two resident records sampled. The deficient practice posed a risk if the service plan was not developed to articulate decisions and agreements, and the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed an initial service plan for directed care level of services, dated February 10, 2023. 2. A review of the signature page of this service plan revealed E1, and the facility's nurse signed and dated the service plan on February 9, 2023. However, where the resident's representative was to sign and date, no signature had been added to the document, however, a date of February 10, 2023, had been added without a signature. 3. In an interview, E1 reported having another document. E1 provided the Compliance Officer with another copy of the service plan with the signature now added, however, the date was still the original date of February 9, 2023. The Compliance Officer observed at the top of this document a line showing this document had been faxed. The fax line stated, "Received 03/03/2023 14:31". Based on R1's date of acceptance, the service plan was not completed within 14 calendar days of R1's date of acceptance. 4. In an interview, E1 acknowledged the service plan was not completed within 14 calendar days of the resident's date of acceptance, and the document from R1's representative did show a fax date of March 3, 2023.