Rivendell Care Home

Based on documentation review and interview, the manager failed to establish, document, and implement policies and procedures to protect the health and safety of a resident to cover qualifications, including required skills and knowledge, education, and experience for employees and volunteers. The deficient practice posed a risk if employees or volunteers did not possess the skills and knowledge to ensure the health and safety of residents. Findings include: 1. A review of the facility's policies and procedures revealed no documentation of a policy covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented. 2. In an interview, E1 acknowledged a policy and procedure covering how a caregiver's or assistant caregiver's skills and knowledge are verified and documented was not available for review at the time of the inspection.

Based on record review and interview, the manager failed to ensure a personnel record for each employee included documentation of the individual's skills and knowledge applicable to the individual's job duties, for two of three personnel members sampled. The deficient practice posed a risk if an employee did not possess the skills and knowledge to meet the needs of residents. Findings include: 1. A review of E2's and E3's personnel record revealed documentation of verification of skills and knowledge was not available for review at the time of inspection. 2. In an interview, E1 reported E1 had verified the caregivers skills and knowledge by working with them for a week after hire, but had not documented the verification. 3. In an interview, E1 acknowledged E2's and E3' personnel record did not include documented verification of E2's and E3' skills and knowledge at the time of the inspection.

Based on record review and interview, the manager failed to ensure a resident provided evidence of freedom from infectious tuberculosis (TB) as specified in Arizona Administrative Code (A.A.C.) R9-10-113, for one of two residents sampled. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of R1's medical record revealed documentation of a TB blood test. However, a TB screening questionnaire for R1 was not available for review. 2. In an interview, E1 acknowledged R1 did not provide valid evidence of freedom from TB as specified in A.A.C. R9-10-113.