Complaint · Compliance (Annual)
12 deficiencies cited
The agency cited 12 deficiencies concerning Fall-prevention training, Policies and procedures, Staff qualifications and training, Medication services, Tuberculosis clearance. Read the official report for the inspector’s evidence and scope.
Findings and correction information
- Fall-prevention trainingA.R.S. § 36-420.01.A
Cited requirement:36-420.01. Health care institutions; fall prevention and fall recovery; training programs; definition A. Each health care institution shall develop and administer a training program for all staff regarding fall prevention and fall recovery. The training program shall include initial training and continued competency training in fall prevention and fall recovery. A health care institution may use information and training materials from the department's Arizona falls prevention coalition in developing the training program.
Correction information is not available in the records reviewed.
- A.R.S. § 36-420.04.C
Cited requirement:36-420.04. 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.
- Policies and proceduresR9-10-803.C.1.g
Cited requirement:C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: g. Cover how a caregiver will respond to a resident's sudden, intense, or out-of-control behavior to prevent harm to the resident or another individual;
Correction information is not available in the records reviewed.
- Policies and proceduresR9-10-803.C.1.m
Cited requirement:C. A manager shall ensure that policies and procedures are: 1. Established, documented, and implemented to protect the health and safety of a resident that: m. Cover methods by which the assisted living facility is aware of the general or specific whereabouts of a resident, based on the level of assisted living services provided to the resident and the assisted living services the assisted living facility is authorized to provide;
Correction information is not available in the records reviewed.
- Staff qualifications and trainingR9-10-806.A.4.a
Cited requirement:A. A manager shall ensure that: 4. 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
Correction information is not available in the records reviewed.
- R9-10-815.F.2.a.i-ii
Cited requirement:F. A manager of an assisted living facility authorized to provide directed care services shall ensure that: 2. There is 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 that meets one of the following: a. Provides access to an outside area that: i. Allows the resident to be at least 30 feet away from the facility, and ii. Controls or alerts employees of the egress of a resident from the facility;
Correction information is not available in the records reviewed.
- Medication servicesR9-10-816.B.3.a-c
Cited requirement:B. If an assisted living facility provides medication administration, a manager shall ensure that: 3. A medication administered to a resident: a. Is administered by an individual under direction of a medical practitioner, b. Is administered in compliance with a medication order, and c. Is documented in the resident's medical record.
Correction information is not available in the records reviewed.
- Medication servicesR9-10-816.F.1
Cited requirement: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.
- R9-10-818.A.2
Cited requirement: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.
- R9-10-818.A.4
Cited requirement: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.
- Tuberculosis clearanceR9-10-113.A.2.a.i-iii
Cited requirement:R9-10-113. 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);
Correction information is not available in the records reviewed.
- Tuberculosis clearanceR9-10-113.A.2.c
Cited requirement:R9-10-113. 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: c. Annually providing training and education related to recognizing the signs and symptoms of tuberculosis to individuals employed by or providing volunteer services for the health care institution;
Correction information is not available in the records reviewed.