24 deficiencies cited
The agency cited 24 deficiencies concerning Tuberculosis clearance, Administration, Personnel, Service Plans, Medical Records, Directed Care Services and other requirements. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- Tuberculosis clearanceR9-10-113.A.2.a-f
Cited requirement:R9-10-113.A.2.a-f. Tuberculosis Screening A. If a health care institution is subject to the requirements of this Section, as specified in an Article in this Chapter, the health care institution's chief administrative officer shall ensure that the health care institution establishes, documents, and implements tuberculosis infection control activities that: 2. Include: a. For each individual who is employed by the health care institution, provides volunteer services for the health care institution, or is admitted to the health care institution and who is subject to the requirements of this Section, baseline screening, on or before the date specified in the applicable Article of this Chapter, that consists of: i. Assessing risks of prior exposure to infectious tuberculosis, ii. Determining if the individual has signs or symptoms of tuberculosis, and iii. Obtaining documentation of the individual's freedom from infectious tuberculosis according to subsection (B)(1); b. If an individual may have a latent tuberculosis infection, as defined in A.A.C. R9-6-1201: i. Referring the individual for assessment or treatment; and ii. Annually obtaining documentation of the individual's freedom fr…
Correction information is not available in the records reviewed.
- AdministrationR9-10-803.A.3.b.i-ii
Cited requirement:R9-10-803.A.3.b.i-ii. Administration A. A governing authority shall: 3. Designate, in writing, a manager who: b. Except for the manager of an adult foster care home, has either a: i. Certificate as an assisted living facility manager issued under A.R.S. § 36-446.04(C), or ii. A temporary certificate as an assisted living facility manager issued under A.R.S. § 36-446.06;
Correction information is not available in the records reviewed.
- AdministrationR9-10-803.A.7
Cited requirement:R9-10-803.A.7. Administration A. A governing authority shall: 7. Except as provided in subsection (A)(6), notify the Department according to A.R.S. § 36-425(I) when there is a change in the manager and identify the name and qualifications of the new manager;
Correction information is not available in the records reviewed.
- AdministrationR9-10-803.A.9
Cited requirement:R9-10-803.A.9. Administration A. A governing authority shall: 9. Ensure compliance with A.R.S. § 36-411 and
Correction information is not available in the records reviewed.
- AdministrationR9-10-803.C.3
Cited requirement:R9-10-803.C.3. Administration C. A manager shall ensure that policies and procedures are: 3. Reviewed at least once every three years and updated as needed.
Correction information is not available in the records reviewed.
- PersonnelR9-10-806.A.4.a-b
Cited requirement:R9-10-806.A.4.a-b. Personnel A. A manager shall ensure that: A caregiver’s or assistant caregiver’s skills and knowledge are verified and documented: a. Before the caregiver or assistant caregiver provides physical health services or behavioral health services, and b. According to policies and procedures;
Correction information is not available in the records reviewed.
- PersonnelR9-10-806.A.7
Cited requirement:R9-10-806.A.7. Personnel A. A manager shall ensure that: 7. Documentation is 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;
Correction information is not available in the records reviewed.
- Tuberculosis clearanceR9-10-806.A.8.a-b
Cited requirement:R9-10-806.A.8.a-b. Personnel A. A manager shall ensure that: 8. A manager, a caregiver, and an assistant caregiver, or an employee or a volunteer who has or is expected to have more than eight hours per week of direct interaction with residents, provides evidence of freedom from infectious tuberculosis: a. On or before the date the individual begins providing services at or on behalf of the assisted living facility, and b. As specified in R9-10-113;
Correction information is not available in the records reviewed.
- Tuberculosis clearanceR9-10-806.C.1.a-c
Cited requirement:R9-10-806.C.1.a-c. Personnel C. A manager shall ensure that a personnel record for each employee or volunteer: 1. Includes: a. The individual’s name, date of birth, and contact telephone number; b. The individual’s starting date of employment or volunteer service and, if applicable, the ending date; and c. Documentation of: i. The individual’s qualifications, including skills and knowledge applicable to the individual’s job duties; ii. The individual’s education and experience applicable to the individual’s job duties; iii. The individual’s completed orientation and in-service education required by policies and procedures; iv. The individual’s license or certification, if the individual is required to be licensed or certified in this Article or in policies and procedures; v. If the individual is a behavioral health technician, clinical oversight required in R9-10-115; vi. Evidence of freedom from infectious tuberculosis, if required for the individual according to subsection (A)(8); vii. Cardiopulmonary resuscitation training, if required for the individual in this Article or policies and procedures; viii First aid training, if required for the individual in this Article or polici…
Correction information is not available in the records reviewed.
- PersonnelR9-10-806.C.2.a-b
Cited requirement:R9-10-806.C.2.a-b. Personnel C. A manager shall ensure that a personnel record for each employee or volunteer: Is maintained: a. Throughout the individual’s period of providing services in or for the assisted living facility, and b. For at least 24 months after the last date the individual provided services in or for the assisted living facility; and
Correction information is not available in the records reviewed.
- Service PlansR9-10-808.A.3.c
Cited requirement:R9-10-808.A.3.c. Service Plans A. Except as required in subsection (B), a manager shall ensure that a resident has a service plan that is established, documented, and implemented that: 3. Includes the following: c The amount, type, and frequency of assisted living services and ancillary services being provided to the resident, including medication administration or assistance in the self-administration of medication;
Correction information is not available in the records reviewed.
- Service PlansR9-10-808.C.1.g
Cited requirement:R9-10-808.C.1.g. Service Plans C. A manager shall ensure that: 1. A caregiver or an assistant caregiver: g. Documents the services provided in the resident’s medical record; and
Correction information is not available in the records reviewed.
- Medical RecordsR9-10-811.C.12
Cited requirement:R9-10-811.C.12. Medical Records C. A manager shall ensure that a resident’s medical record contains: 12. A medication order from a medical practitioner for each medication that is administered to the resident or for which the resident receives assistance in the self-administration of the medication;
Correction information is not available in the records reviewed.
- Medical RecordsR9-10-811.C.13.a-d
Cited requirement:R9-10-811.C.13.a-d. Medical Records C. A manager shall ensure that a resident’s medical record contains: 13. Documentation of medication administered to the resident or for which the resident received assistance in the self-administration of medication that includes: a. The date and time of administration or assistance; b. The name, strength, dosage, and route of administration; c. The name and signature of the individual administering or providing assistance in the self-administration of medication; and d. An unexpected reaction the resident has to the medication;
Correction information is not available in the records reviewed.
- Medical RecordsR9-10-811.C.17
Cited requirement:R9-10-811.C.17. Medical Records C. A manager shall ensure that a resident’s medical record contains: 17. Documentation of notification of the resident of the availability of vaccination for influenza and pneumonia, according to A.R.S. § 36-406(1)(d);
Correction information is not available in the records reviewed.
- Directed Care ServicesR9-10-815.C.6.a-b
Cited requirement:R9-10-815.C.6.a-b. Directed Care Services C. In addition to the requirements in R9-10-808(A)(3), a manager shall ensure that the service plan for a resident receiving directed care services includes: 6. Documentation: a. Of the resident’s weight, or b. From a medical practitioner stating that weighing the resident is contraindicated;
Correction information is not available in the records reviewed.
- Medication ServicesR9-10-817.B.3.b
Cited requirement:R9-10-817.B.3.b. Medication Services B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: b. Is administered in compliance with a medication order, and
Correction information is not available in the records reviewed.
- Food ServicesR9-10-818.A.6
Cited requirement:R9-10-818.A.6. Food Services A. A manager shall ensure that: 6. A resident is provided a diet that meets the resident’s nutritional needs as specified in the resident’s service plan;
Correction information is not available in the records reviewed.
- Emergency and Safety StandardsR9-10-819.A.2
Cited requirement:R9-10-819.A.2. Emergency and Safety Standards A. A manager shall ensure that: 2. The disaster plan required in subsection (A)(1) is reviewed at least once every 12 months;
Correction information is not available in the records reviewed.
- Emergency and Safety StandardsR9-10-819.A.4
Cited requirement:R9-10-819.A.4. Emergency and Safety Standards A. A manager shall ensure that: 4. A disaster drill for employees is conducted on each shift at least once every three months and documented;
Correction information is not available in the records reviewed.
- Emergency and Safety StandardsR9-10-819.A.7.a
Cited requirement:R9-10-819.A.7.a. Emergency and Safety Standards A. A manager shall ensure that: 7. If the assisted living facility is authorized to provide directed care services, an elopement drill for employees: a. Conduct an elopement drill every six months on each shift and document the date, time, and description of each drill; and
Correction information is not available in the records reviewed.
- Hazardous-material storageR9-10-820.A.11
Cited requirement:R9-10-820.A.11. Environmental Standards A. A manager shall ensure that: 11. Poisonous or toxic materials stored by the assisted living facility are maintained in labeled containers in a locked area separate from food preparation and storage, dining areas, and medications and are inaccessible to residents;
Correction information is not available in the records reviewed.
- Environmental StandardsR9-10-820.A.2
Cited requirement:R9-10-820.A.2. Environmental Standards A. A manager shall ensure that: 2. A pest control program that complies with A.A.C. R3-8201(C)(4) is implemented and documented;
Correction information is not available in the records reviewed.
- Environmental StandardsR9-10-820.A.6
Cited requirement:R9-10-820.A.6. Environmental Standards A. A manager shall ensure that: 6. Hot water temperatures are maintained between 95º F and 120º F in areas of an assisted living facility used by residents;
Correction information is not available in the records reviewed.