Sacred Heart Homes, INC

Based on the documentation review and interview, the manager failed to ensure that policies and procedures were reviewed at least once every three years and updated as needed. The deficient practice posed a risk as policies and procedures reinforce and clarify standards expected of employees. Findings include: 1. A review of the facility's policies and procedures revealed no documentation indicating that the policies and procedures were reviewed and updated as needed. 2. In an interview, E2 acknowledged that the policies and procedures were not reviewed at least once every three years and updated as needed.

Based on observation, documentation review, and interview, the manager failed to ensure that medication administration policies and procedures were reviewed and approved by a medical practitioner, registered nurse, or pharmacist. Findings include: 1. During the environmental tour, the Compliance Officer observed that the facility provided medication administration services. 2. A review of facility policies and procedures revealed a policy titled "Medication Policy and Procedure.” However, the medication policy and procedure were not reviewed, signed, and dated by a medical practitioner, registered nurse, or pharmacist. 3. In an interview, E2 acknowledged that the facility's policies and procedures for medication administration were not reviewed and approved by a medical practitioner, registered nurse, or pharmacist

Based on the documentation review and interview, the manager failed to ensure that a pest control program that complied with A.A.C. R3-8-201(C)(4) was implemented and documented. Findings include: 1 . During an inspection, the Compliance Officer requested to review the facility's pest control program. However, documentation of the program was not available for review during the inspection. 2 . In an interview, E2 acknowledged the facility had no pest control program that complies with A.A.C. R3-8-20l(C)(4) implemented and documented.

Based on record review and interview, the administrator failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. A review of R2's medical record revealed a service plan dated April 27, 2023 for directed care services. The service plan stated "Elimination: Incontinent...disposal undergarment...dependent". However, a frequency of how often the service was to be provided to R2 was not documented. 2. A review of R1's medical record revealed an activities of daily living (ADL) document for June 2023. However, oral care was not documented in R1's medical record as provided. 3. A review of E3's personnel record revealed a fingerprint clearance card with an expiration date of September 30, 2022. However, documentation of a current fingerprint clearance card for E3 was not available for review. 4. A review of E4's personnel record revealed a fingerprint clearance card with an expiration date of September 8, 2022. However, documentation of a current fingerprint clearance card for E4 was not available for review. 5. In an interview, E1 acknowledged documentation required by this Article was not provided to the Department within two hours after a Department request.

Based on observation, record review, documentation review, and interview, the manager failed to ensure a personnel record included documentation of compliance with the requirements in Arizona Revised Statutes (A.R.S.) \'a7 36-411(A), for two of three personnel members sampled. The deficient practice posed a risk if E3 and E4 were a danger to a vulnerable population, the Department was unable to determine substantial compliance as the documentation was not in the personnel record during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A.R.S. \'a7 36-411(A) states: "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institution, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have valid fingerprint clearance cards that are issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days of employment or beginning volunteer work or contracted work." 2. At the time of arrival, the Compliance Officer observed E4 to be the only staff working onsite. 3. A review of E3's personnel record revealed a fingerprint clearance card with an expiration date of September 30, 2022. However, documentation of a current fingerprint clearance card for E3 was not available for review. 4. A review of the Arizona Department of Public Safety (DPS) fingerprint clearance card verification website revealed E3's fingerprint clearance card status stated "In Process". 5. A review of E3's personnel record revealed a letter from DPS, dated February 24, 2023. The letter stated "Re: AZAFIS Fingerprint Unit (AFPU) Reprint Request...AFPU was unable to process the fingerprint card submitted with your application due to the quality of the prints..." E3's personnel record also contained a letter from DPS, dated March 28, 2023. The letter stated "The Department of Public Safety (DPS) was notified by the FBI they were unable to process the fingerprint card submitted with your application due to the insufficient quality of the prints..." 6. A review of facility documentation revealed a letter from the City of Peoria, dated May 25, 2023. The letter stated "[E3] At your request, th

Based on record review and interview, the manager failed to ensure a written service plan included the frequency of assisted living services provided to the resident, for one of two residents sampled. The deficient practice posed a risk as the service provided were unable to be verified and the required documentation was not provided during the inspection, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R2's medical record revealed a service plan dated April 27, 2023 for directed care services. The service plan stated "Elimination: Incontinent...disposal undergarment...dependent". However, a frequency of how often the service was to be provided to R2 was not documented. 2. In an interview, E1 reported R2 received incontinence care daily. E1 acknowledged the service plan for R2 did not include the frequency of the aforementioned assisted living service to be provided to R2.

Based on record review and interview, the manager failed to ensure a caregiver or assistant caregiver documented the services provided to a resident in the resident's medical record, for one of two residents sampled. The deficient practice posed a risk as the services provided were unable to be verified and the required documentation was not provided during the inspection, the Department was unable to determine substantial compliance as the documentation was not in the medical record during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of R1's medical record revealed a service plan dated February 5, 2023 for personal care services. The service plan stated "Oral Care: twice daily". 2. A review of R1's medical record revealed an activities of daily living (ADL) document for June 2023. However, oral care was not documented in R1's medical record as provided. 3. In an interview, E1 reported caregivers provided oral care to R1, however, it was not documented in the ADL document. E1 acknowledged the aforementioned service was not documented in R1's medical record as provided.