Peoria Vista

Based on documentation review, record review, and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for two of three personnel members sampled. Findings include: 1. A review of E1's personnel record revealed E1 was hired as a caregiver on December 13, 2023. The record included E1's application for employment which reflected employment history between 2019 and E1's date of hire. However, evidence of good faith efforts to contact E1's previous employers to obtain information about E1's fitness to work in an assisted living environment was not available for review. 2. A review of E3's personnel record revealed E3 was hired as a manager on September 1, 2023. The record included E3's application for employment which reflected employment history between 2022 and E3's date of hire. However, evidence of good faith efforts to contact E3's previous employers to obtain information about E3's fitness to work in an assisted living environment was not available for review. 3. In an interview E1 acknowledged the governing authority failed to ensure compliance with A.R.S. \'a7 36-411 pertaining to E1's and E3's employment.

Based on documentation review, observation, and interview, the manager failed to ensure for a facility authorized to provide directed care services, there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort and provided access to an outside area which allowed the resident to be at least 30 feet away from the facility and controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a potential elopement risk for residents. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. During a tour of the facility the Compliance Officer observed a door on the back of the facility which exited to the back patio and back yard area. The door was equipped with a key turn dead bolt lock, a non-locking handle and a door chime designed to alert employees when the door opened. The deadbolt lock did not have a key inserted and was not engaged as the Compliance Officer was able to easily open the door. When the door opened, no door alarm sounded to alert employees of the egress of a resident from the facility. 3. In an interview, E1 acknowledged the patio door did not have an alarm or controls to alert employees of a resident's egress from the facility.

Based on record review and interview, the manager failed to ensure medication administered to a resident is administered by an individual under direction of a medical practitioner for two of two residents sampled. Findings include: 1. A review of R1's and R2's s medical record revealed a current service plan which indicated R1 and R2 received medication administration. R1's and R2's medical record reveled a medication administration record which indicated R1 and R2 were being administered medication as prescribed. However, R1's and R2's medical record did not contain evidence of documentation of an individual authorized by a medical practitioner to administer medication under the direction of the medical practitioner. 2. A review of facility policy and procedures revealed a policy regarding medication administration which stated: "Only individuals designated by the physician or medical practitioner will be allowed to administer medication." 3. In an interview E1 acknowledged R1 and R2 were administered medication as ordered, however authorization to administer medication had not been obtained from R1's or R2's medical provider.

Based on documentation review and interview, the manager failed to ensure a disaster drill for employees was conducted on each shift at least once every three months and documented. Findings include: 1. A review of facility staffing schedules revealed the facility had two shifts, 7:00 a.m. - 7:00 p.m. and 7:00 p.m.-7:00 a.m. 2. A review of facility documentation revealed documentation of disaster drills for employees on both shifts conducted in January and April, 2023. However, evidence of documentation of disaster drills for employees working 7:00 p.m.-7:00 a.m., conducted in July 2023, or in October 2023 was not available for review. 3. In an interview, E1 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented as required. Technical assistance regarding this requirement was provided during an on-site compliance survey conducted on November 15, 2022.