St. Luke's Home

Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented, and implemented tuberculosis (TB) infection control activities required in R9-10-113.A.2.a-f. Findings include: 1. A review of R2’s, R3's, and R4’s medical records revealed each record included a negative test for TB. However, each person’s documentation of freedom from infectious TB did not include a, “baseline screening that consists of assessing risks of prior exposure to infectious tuberculosis or determining if the individual has signs or symptoms of tuberculosis,” per R9-10-113.A.2.a. 2. In an interview, E1 acknowledged the health care institution had not documented and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f. Technical assistance was provided for this rule during the on-site compliance inspection conducted on June 6, 2022, the on-site compliance inspection conducted on June 7, 2023, and the on-site compliance and complaint inspection conducted on July 2, 2024.

Based on documentation review and interview, the manager failed to ensure a dog residing at the facility was vaccinated against rabies. The deficiency practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Finding include: 1. A review of facility documentation revealed a document titled, "St. Luke's Home Pet Information." The document indicated R6 resided at the facility with a cat, C1, and stated C1's rabies expiration date was, "2/7/2023." The document indicated R7 resided at the facility with a dog, D1, and stated D1 was, "In process with rabies and license." 2. The Compliance Officer requested and was not provided with documentation of a current rabies vaccination for C1 and D1. 3. In an interview, E3 acknowledged documention of rabies vaccinations for the two animals had not been provided for review within two hours after a Department request.

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 to include initial training and continued competency training in fall prevention and fall recovery. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. A review of the facility's policies and procedures, reviewed January 1, 2023, revealed a policy titled, "Fall and injury policy and procedure." The policy stated, "The Manager or Designee will ensure that all caregivers at the time of their employment will review the Fall and Injury policy and procedure before providing services to the residents." However, the policy did not require all staff to receive initial training and did not cover continued competency training. 2. A review of E4's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 3. A review of E5's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 4. A review of E6's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 5. A review of E7's personnel record revealed documentation of initial training or continued competency training in fall prevention and fall recovery was not available for review. 6. In an interview, E1, E2, and E3 acknowledged the facility had not developed and administered a training program for all staff regarding fall prevention and fall recovery. This is a repeat deficiency from the on-site compliance inspection conducted on June 6, 2022.

Based on documentation review and interview the manager failed to ensure a dog residing at the facility was licensed consistent with local ordinances. The deficiency practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Finding include: 1. A review of facility documentation revealed a document titled, "St. Luke's Home Pet Information." The document indicated R7 resided at the facility with a dog, D1, and that D1 was, "In process with rabies and license." 2. The Compliance Officer requested and was not provided with documentation of a Pima County license for D1. 3. In an interview, E1, E2, and E3 acknowledged a license for D1 had not been provided for review within two hours after a Department request.

Based on documentation review, record review, and interview, the manager failed to ensure the facility obtained a written determination from a behavioral health professional or medical practitioner, upon acceptance and every six months thereafter, stating the resident's needs could be met by the facility within the facility's scope of services, for one of one resident sampled who received behavioral care. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. R9-10-101(29) states, "Behavioral care a. Means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services." 1. A review of R5's medical record revealed service plan dated May 18, 2023 for Personal care services including medication administration. The service plan indicated R5's medical diagnosis were: Schizophrenia and Paranoia. The service plan indicated R5 received behavioral health services from a behavioral health professional on an intermittent basis. 2. A review of R5's medical record revealed a document titled, "Determination of Admission," signed by a physician on July 13, 2021. This document stated R5 required continuous behavioral health services and included the explanation, "[Age of R5] with schizophrenia/schizo-affective D/O and Chronic Severe Cognitive function - sees Psychiatrist [third party BHP at OTC clinic]." 3. A review of R5's medical record revealed no documentation indicating R5's behavioral health professional or medical practitioner examined R5 upon acceptance and every six months thereafter, reviewed the facility's scope of services, and signed and dated a determination stating R5's needs were able to be met by the facility. 4. In an interview, E1, E2, and E3 acknowledged the required evaluation and determination for R5 had not been provided for review.

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. Findings include: 1. On June 7, 2023, the Compliance Officer requested the following document during the on-site inspection: - Fall prevention and fall recovery training for E4, E5, E6, and E7; and - The determination for R5 required by R9-10-812.1-3 for residents receiving behavioral care; and -Pima County license for D1;and -Current rabies vaccinations for C1 and D1; However, this documentation was not provided for review. 2. In an interview, E1, E2, and E3 acknowledged the requested documentation had not been provided for review.

Based on record review and interview, the manager failed to ensure a service plan, for a resident who required behavioral care, was reviewed by a medical practitioner or behavioral health professional, for one of one residents sampled who required behavioral care. R9-10-101(29) states, "Behavioral care a. Means limited behavioral health services, provided to a patient whose primary admitting diagnosis is related to the patient's need for physical health services, that include: i. Assistance with the patient's psychosocial interactions to manage the patient's behavior that can be performed by an individual without a professional license or certificate including: (1) Direction provided by a behavioral health professional, and (2) Medication ordered by a medical practitioner or behavioral health professional; or ii. Behavioral health services provided by a behavioral health professional on an intermittent basis to address the patient's significant psychological or behavioral response to an identifiable stressor or stressors; and b. Does not include court-ordered behavioral health services." Findings include: 1. A review of R5's medical record revealed service plan dated May 18, 2023, for Personal care services including medication administration. The service plan indicated R5's medical diagnosis were: Schizophrenia and Paranoia. The service plan indicated R5 received behavioral health services from a behavioral health professional on an intermittent basis. However, the service plan was not reviewed by a behavioral health professional or medical practitioner. 2. A review of R5's medical record revealed a document titled, "Determination of Admission," signed by a physician on July 13, 2021. This document stated R5 required continuous behavioral health services and included the explanation, "[Age of R5] with schizophrenia/schizo-affective D/O and Chronic Severe Cognitive function - sees Psychiatrist [third party BHP at OTC clinic]." 3. In an interview, E1, E2, and E3 acknowledged R5's service plan had not been reviewed by a medical practitioner or behavioral health practitioner.