Complaint · Compliance (Annual)
21 deficiencies cited
The agency cited 21 deficiencies concerning Personnel, Tuberculosis clearance, Residency and Residency Agreements, 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
- A.R.S. § 36-420.04.C
Cited requirement:A.R.S. § 36-420.04.C. Emergency responders; patient information; hospitals; discharge planning; patient screenings; discharge document C. Each assisted living center and assisted living home must maintain a standardized form for each resident that includes the information prescribed in subsection A of this section, except for the information prescribed in subsection A, paragraph 1 of this section, which shall be provided at the time the emergency responder is contacted. Each assisted living center and assisted living home shall periodically update this form for each resident as necessary.
Correction information is not available in the records reviewed.
- R9-10-804.3
Cited requirement:R9-10-804.3. Quality Management A manager shall ensure that: 3. The report required in subsection (2) and the supporting documentation for the report are maintained for at least 12 months after the date the report is submitted to the governing authority.
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.B.4.a-b
Cited requirement:R9-10-806.B.4.a-b. Personnel B. A manager of an assisted living home shall ensure that: 4. At least the manager or a caregiver is present at an assisted living home when a resident is present in the assisted living home and: a. Except for nighttime hours, the manager or caregiver is awake; and b. If the manager or caregiver is not awake during nighttime hours: i. The manager or caregiver can hear and respond to a resident needing assistance; and ii. If the assisted living home is authorized to provide directed care services, policies and procedures are developed, documented, and implemented to establish a process for checking on a resident receiving directed care services during nighttime hours to ensure the resident’s health and safety.
Correction information is not available in the records reviewed.
- Tuberculosis clearanceR9-10-807.A.1-2
Cited requirement:R9-10-807.A.1-2. Residency and Residency Agreements A. Except as provided in R9-10-808(B)(2), a manager shall ensure that a resident provides evidence of freedom from infectious tuberculosis: 1. Before or within seven calendar days after the resident’s date of occupancy, and 2. As specified in R9-10-113
Correction information is not available in the records reviewed.
- Residency and Residency AgreementsR9-10-807.B.1.a-b
Cited requirement:R9-10-807.B.1.a-b. Residency and Residency Agreements B. A manager shall ensure that before or at the time of acceptance of an individual, the individual submits documentation that is dated within 90 calendar days before the individual is accepted by an assisted living facility and: 1. If an individual is requesting or is expected to receive supervisory care services, personal care services, or directed care services: a. Includes whether the individual requires: i. Continuous medical services, ii. Continuous or intermittent nursing services, or iii. Restraints; and b. Is dated and signed by a: i. Physician, ii. Registered nurse practitioner, iii. Registered nurse, or iv. Physician assistant; and
Correction information is not available in the records reviewed.
- Residency and Residency AgreementsR9-10-807.D.1-10
Cited requirement:R9-10-807.D.1-10. Residency and Residency Agreements D. Before or at the time of an individual’s acceptance by an assisted living facility, a manager shall ensure that there is a documented residency agreement with the assisted living facility that includes: 1. The individual’s name; 2. Terms of occupancy, including: a. Date of occupancy or expected date of occupancy, b. Resident responsibilities, and c. Responsibilities of the assisted living facility; 3. A list of the services to be provided by the assisted living facility to the resident; 4. A list of the services available from the assisted living facility at an additional fee or charge; 5. For an assisted living home, whether the manager or a caregiver is awake during nighttime hours; 6. The policy for refunding fees, charges, or deposits; 7. The policy and procedure for a resident to terminate residency, including terminating residency because services were not provided to the resident according to the resident’s service plan; 8. The policy and procedure for an assisted living facility to terminate residency; 9. The complaint process; and 10. The manager’s signature and date signed.
Correction information is not available in the records reviewed.
- Service PlansR9-10-808.A.5.a-d
Cited requirement:R9-10-808.A.5.a-d. 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: 5. When initially developed and when updated, is signed and dated by: a. The resident or resident’s representative; b. The manager; c. If a review is required in subsection (A)(3)(d), the nurse or medical practitioner who reviewed the service plan; and d. If a review is required in subsection (A)(3)(e)(ii), the medical practitioner or behavioral health professional who reviewed the service plan.
Correction information is not available in the records reviewed.
- Medical RecordsR9-10-811.A.1
Cited requirement:R9-10-811.A.1. Medical Records A. A manager shall ensure that: 1. A medical record is established and maintained for each resident according to A.R.S. Title 12, Chapter 13, Article 7.1;
Correction information is not available in the records reviewed.
- Tuberculosis clearanceR9-10-811.C.7
Cited requirement:R9-10-811.C.7. Medical Records C. A manager shall ensure that a resident’s medical record contains: 7. Except as allowed in R9-10-808(B)(2), documentation of freedom from infectious tuberculosis as required in R9-10-807(A);
Correction information is not available in the records reviewed.
- Directed Care ServicesR9-10-815.C.1
Cited requirement:R9-10-815.C.1. 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: 1. The requirements in R9-10-814(F)(1) through (3);
Correction information is not available in the records reviewed.
- Directed Care ServicesR9-10-815.C.3
Cited requirement:R9-10-815.C.3. 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: 3. Cognitive stimulation and activities to maximize functioning;
Correction information is not available in the records reviewed.
- Directed Care ServicesR9-10-815.C.5
Cited requirement:R9-10-815.C.5. 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: 5. Encouragement to eat meals and snacks;
Correction information is not available in the records reviewed.
- Directed Care ServicesR9-10-815.E.1-2
Cited requirement:R9-10-815.E.1-2. Directed Care Services E. A manager shall ensure that: 1. A bell, intercom, or other mechanical means to alert employees to a resident’s needs or emergencies is available in a bedroom being used by a resident receiving directed care services; or 2. An assisted living facility has implemented another means to alert a caregiver or assistant caregiver to a resident’s needs or emergencies.
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.
- Medication ServicesR9-10-817.F.1
Cited requirement:R9-10-817.F.1. Medication Services F. When medication is stored by an assisted living facility, a manager shall ensure that: 1. Medication is stored in a separate locked room, closet, cabinet, or self-contained unit used only for medication storage;
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.3.a-d
Cited requirement:R9-10-819.A.3.a-d. Emergency and Safety Standards A. A manager shall ensure that: 3. Documentation of the disaster plan review required in subsection (A)(2) includes: a. The date and time of the disaster plan review; b. The name of each employee or volunteer participating in the disaster plan review; c. A critique of the disaster plan review; and d. If applicable, recommendations for improvement;
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.
- Environmental StandardsR9-10-820.A.10
Cited requirement:R9-10-820.A.10. Environmental Standards A. A manager shall ensure that: 10. Oxygen containers are secured in an upright position;
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.