Olivia White Hospice Home, the

Based on record review and interview the health care institution failed to develop and administer a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01. Findings include: 1. Review of facility documentation failed to reveal that the health care institution had developed a training program for all staff regarding fall prevention and fall recovery as required in A.R.S. \'a7 36-420.01. 2. During an interview, E2 acknowledged the required documentation was not available for review.

Based on documentation review and interview, the manager failed to submit a documented report to the governing authority per the frequency established in the plan. Findings include: 1. Review of the facility quality management plan revealed that a report was to be submitted to the governing authority on a "quarterly" basis. 2. The last report submitted to the governing authority was dated January 4, 2023. 3. During an interview, E1 stated, "I haven't done that yet."

Based on documentation review and interview, the chief administrative officer failed to ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that include subsections a. through f. of this rule: Findings include: 1. Review of facility policies and procedures failed to reveal documentation indicating that the health care institution had established and documented tuberculosis infection control policies and procedures that include subsections a. through f. of this rule. 2. During an interview, E1 acknowledged that the required documentation was not available for review.