Truval Assisted Living Home

Based on documentation review and interview, the manager failed to ensure a plan was implemented for an ongoing quality management program. Findings include: 1. A review of the facility's policy and procedure manual, reviewed June 20, 2022, revealed a policy titled, "Quality Management," which stated, "The Manager or Manager's Designee will ensure that all non-medical emergency events...will be documented in the resident record...and a notation will be documented in the facility Quality Management book...Incidents involving contacting medial services will be documented on a written incident report form...A notation regarding the incident will be documented in the facility Quality Management Program Manual...One time on a bi-annually basis the Manager will evaluate the data utilizing a line graph to identify trends and specific concerns...The Manager will evaluate and identify changes or actions necessary to prevent recurrence of the incident. The information will be documented in a report..This statistical data and evaluation will be reported to the Governing Authority...The incident reports and the supporting documentation for the repots are maintained for twelve months after the date the report is submitted to the Governing Authority." 2. The Compliance Officer requested the quality management forms and the quality management reports. However, no reports for calendar year 2022 or 2023 were available for review. 3. In an interview, E1 acknowledged the facility's ongoing quality management program had not been implemented and documentation required in the facility's Quality Management program for calendar year 2022 or 2023 was not available for review.

Based on observation, documentation review, and interview, the manager failed to ensure documentation was maintained for at least 12 months after the last date on the documentation of the caregivers and assistant caregivers working each day, including the hours worked by each. Findings include: 1. During a facility tour, the Compliance Officer observed no evidence of a personnel schedule documenting the caregivers working each day, including the hours worked by each. 2. In an interview, the Compliance Officer asked E2 to provide the facility's personnel schedules for the past twelve months. E2 reported being unable to locate any caregivers schedules and admitted to not knowing when the last schedule had been created. E2 reported only three care providers at the facility. 3. In an interview, E1 acknowledged not maintaining caregivers schedules for at least twelve months.

Based on observation, record review and interview the manager failed to ensure at least the manager or a caregiver was present at the assisted living home when a resident was present in the assisted living home. The deficient practice posed a risk as no qualified employee was present to meet a resident's needs. Findings include: 1. Upon arriving at the facility, the Compliance Officer observed E3 was the only employee present at the facility, which had a census of five residents. 2. A review of E3's personnel record revealed E3 was hired in 2016 as an assistant caregiver. Evidence of E3's certification as a caregiver was unavailable for review. 3. In an interview, E1 reported E3 was not a certified caregiver, but rather an assistant caregiver. E1 advised E3 was routinely the only employee at the facility. E1 acknowledge a manager or a caregiver was not present at the assisted living home when residents were present at the assisted living home.

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 direct health and safety risk to residents if the facility was not aware of their general whereabouts. Findings include: 1. A review of the Department's documentation revealed the facility was authorized to provide directed care services. 2. Upon arrival at the facility the Compliance Officer observed the main entrance door of the facility, equipped with a key operated dead bolt lock and a device designed to alert employees of the egress of a resident from the facility, was completely open. The Compliance Officer also observed the only care provider present at the facility arrive at the front door from a back room, on the east side of the facility. Upon entrance, the Compliance Officer observed the care provider return to a back room on the east side of the facility, out of view of the door. During a tour of the facility, the Compliance Officer observed no fewer than three ambulatory residents, occupying units on both the east and west side of the facility. 3. In an interview, E2 advised the front door had been left open to allow fresh air into the facility. 4. In an interview, E1 acknowledged the front door, when left fully open, did not have an alarm or controls to alert employees of a resident's egress from the facility.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. A review of facility documentation revealed an annual disaster plan review was conducted on July 20, 2022, however evidence of documentation of an annual disaster plan review since 2022 was not available. 2. In an interview, E1 acknowledged a disaster plan was not reviewed at least once every twelve months.

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. The deficient practice posed a health and safety risk to residents if employees were unable to implement a disaster drill an emergency. Findings include: 1. A review of facility documentation revealed a disaster drill for employees on all shifts was conducted on June 5, 2022, however documentation for any disaster drill conducted after June 5, 2022 was unavailable for review. 2. In an interview, E2 acknowledged a disaster drill for employees was not conducted on each shift at least once every three months and documented as required.

Based on documentation review and interview, the manager failed to ensure an evacuation drill for employees and residents was conducted at least once every six months and included all individuals on the premises. The deficient practice posed a health and safety risk to residents and employees if the employees were unable to implement the evacuation plan. Findings include: 1. A review of facility's employee and resident evacuation drills revealed a drill had been conducted and documented on January 11, 2022. However, evidence of documentation of an evacuation drill conducted since January 11, 2022 was unavailable for review. 2. In an interview, E1 acknowledged documentation was not available showing evacuation drills were conducted at least once every six months and included all individuals on the premises.