Sandra Baker Adult Foster Care

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. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of facility documentation revealed a staffing schedule for the month of August 2023. The schedule revealed the facility maintained two shifts: -7:30 AM - 7:30 PM (first shift) -7:30 PM - 7:30 AM (second shift) 2. A review of facility documentation revealed the following disaster drills were conducted: -May 1, 2022 (first shift, second shift) -November 5, 2022 (first shift, second shift) -May 15, 2023 (first shift, second shift) 3. In an interview, E1 acknowledged disaster drills had not been conducted on each shift at least once every three months. Technical assistance was provided on this Rule during the compliance inspection conducted on May 11, 2022.

Based on documentation review, record review and interview, the manager failed to ensure documentation required by Article 8 for in-service educato=ion 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. The Compliance Officer requested the following at 9:15 AM: -Employee disaster drills -Resident and employee evacuation drills -Disaster plan and annual review -Two personnel records -Two medical records -Policies and procedures -Fall Prevention and Fall Recovery training program 2. The Compliance Officer conducted the exit interview with E1 at 11:30 AM and the following documentation had not been provided to the Department for review: -Fall Prevention and Fall Recovery training program 3. In an interview, E1 acknowledged a training program for fall prevention and fall recovery was not available for review. E1 reported E1 developed and implemented a training program for fall prevention and fall recovery but was unsure where the training program or training documentation was.

Based on record review and interview, the governing authority failed to ensure compliance with A.R.S. \'a7 36-411, for one of two employees sampled. The deficient practice posed a risk if E1 was a danger to a vulnerable population. Findings include: A.R.S. \'a7 36-411(A) states "Except as provided in subsections F, G, H and I 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 or contracted persons or volunteers who provide medical services, nursing services, behavioral health services, health-related services, home health services or 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... "Supportive Services" has the same meaning prescribed in section 36-151." A.R.S. \'a7 36-151(6) states supportive services means "... services may include, but not limited to, nutrition counseling, meals services, homemaker services, general maintenance services and transportation services." Findings include: 1. A review of E1's personnel record revealed a fingerprint clearance card, issued on August 30, 2012 and expired on August 30, 2018. However, documentation of an updated fingerprint clearance card was not available for review. 2. A review of the Arizona Department of Public Safety (DPS) fingerprint verification website revealed E1's card was issued on August 30, 2012 and expired on August 30, 2018. 3. In an interview, E1 acknowledged E1's fingerprint clearance card had expired. E1 reported to be unaware of the statute change requiring personnel to renew fingerprint clearance cards, regardless of continuous employement status.

Based on documentation review, 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. The deficient practice posed a risk as organized instruction and information related to resident care and safety was not developed and implemented. Findings include: 1. A review of facility documentation revealed a training program for fall prevention and fall recovery was not available for review. 2. A review E1's and E2's personnel records revealed initial training and continued competency training in fall prevention and fall recovery was not available for review. 3. In an interview, E1 acknowledged a training program for fall prevention and fall recovery was not available for review. E1 reported E1 developed and implemented a training program for fall prevention and fall recovery but was unsure where the training program or training documentation was. Technical assistance was provided on this Statute during the compliance inspection conducted on May 11, 2022.