Paradise Valley Care Home, LLC

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) § 36-411(A) for two of the three sampled employees. The deficient practice posed a risk if the individual was a danger to a vulnerable population. Findings include: 1. A.R.S. § 36-411 states, "Owners shall make documented, good faith efforts to: Verify the current status of a person's fingerprint clearance card." 2. A review of E2's personnel record did not include documentation verifying E2’s fingerprint clearance card. 3. A review of E3’s personnel record did not include documentation verifying E3's fingerprint clearance card. 3. In an interview, E1 acknowledged that E2’s and E3’s fingerprint clearance cards were not verified, and the governing authority failed to ensure compliance with A.R.S. § 36-411.

Based on the 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. A review of the facility's policies and procedures revealed the facility's disaster plan; however, no documentation was available for the Compliance Officer to review. 2. In an interview, E1 acknowledged that the facility's disaster plan was not reviewed at least once every 12 months.

Based on observation, record review, and interview, the manager failed to ensure a personnel record for each employee or volunteer included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(C), for one of three personnel records sampled. Findings include: 1. A.R.S. \'a7 36-411(C) states: "C. Owners shall make documented, good faith efforts to: 1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency..." 2. The Compliance Officer observed E2 working at the facility for the duration of the time the Compliance Officer was on site. 3. A review of E2's personnel record revealed E2 was hired as a caregiver. E2's personnel record revealed no documented good faith efforts to contact previous employers to obtain information or recommendations relevant to E2's fitness to work in a residential care institution. 4. In an interview, E2 reported E2 was scheduled to work twenty-four hour shifts on every day of the week except Fridays. E2 reported E2 had been working this schedule for at least "a few months." E2 reported E2 was not sure whether E1 contacted E2's previous employers prior to E2 starting work at the facility. 5. In a telephonic interview, E1 acknowledged the personnel record for E2 did not include documentation of compliance with the requirements in A.R.S. \'a7 36-411(C).

Based on record review and interview, the manager failed to ensure a resident's written service plan included the amount and frequency of assisted living services to be provided to the resident, for two of two current residents sampled. The deficient practice posed a risk as the service plan did not reinforce and clarify services to be provided to a resident. Findings include: 1. A review of R1's medical record revealed a service plan dated January 28, 2023 for personal care services. The service plan indicated R1 was to receive the following assisted living services: -"Bathing: 1 to Assist, Shower"; and -"Skin Care: 1 to Assist, Skin Assessment Completed for each area of concern." However, the service plan did not include the amount and frequency of the above services provided for R1. 2. A review of R2's medical record revealed a service plan dated March 30, 2023 for directed care services. The service plan indicated R2 was to receive the following assisted living services: -"Bathing: Max, Dependent, Shower"; -"Comb Hair: Max, Dependent"; and -"Oral Care: Mod, 1 to Assist, Natural Teeth, Brush Teeth." However, the service plan did not include the amount and frequency of the above services provided for R2. 3. In a telephonic interview, E1 acknowledged R1's and R2's service plans did not include the amount and frequency of the aforementioned assisted living services to be provided for R1 and R2. Technical assistance was provided for this rule during the on-site compliance inspection conducted on July 24, 2020.

Based on documentation review, record review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, the means of exiting the facility for a resident who did not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility to the outside area allowing the resident to be at least 30 feet away from the facility. Findings include: 1. A review of Department documentation revealed the facility was authorized to provide directed care services. 2. A review of facility policies and procedures revealed a policy titled "Protocol for Wandering Residents" which stated, "Caregivers will maintain security of locks on the front door, yards and hazardous areas at all times...There is a means of exiting the Facility for a resident which...provides access to an outside area that allows the resident to be at least 30 feet away from the Facility, and controls or alerts personnel of the egress of a resident from the Facility." 3. A review of R2's medical record revealed a service plan which indicated R2 received directed care services. 4. During the environmental inspection of the facility, the Compliance Officer observed a double door leading from the facility's kitchen and dining area into the back yard. The door had a mechanism to alert employees of the egress of a resident from the facility, however the mechanism did not sound when the Compliance Officer opened the door. The Compliance Officer observed the outside area in the backyard allowed residents to be at least 30 feet away from the facility. The Compliance Officer also observed unlocked gates on the North and South ends of the yard. 5. In a telephonic interview, E1 acknowledged the device to alert employees of the egress of a resident from the facility to the outside area through the back door was not in working order. E1 reported E1 had called the company which installed alarms on the doors to come fix the issue. E1 also acknowledged the gate in the facility's back yard did not control or alert employees of the egress of a resident from the facility. E1 reported the facility had hired a company to do work in the backyard and had taken the locks off of the back gates while the work was being completed. E1 acknowledged the back door and back yard gate were not controlled and did not alert employees of the egress of a resident from the facility.