Magnolia Homecare at Mulberry LLC.

“Based on documentation review, observation, record review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of three personnel sampled. The deficient practice posed a risk if E3 was a danger to a vulnerable population. Findings include:  1. A.R.S. § 36-411(C)(2) states, "Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to: 2. Verify the current status of a person’s fingerprint clearance card." 2. While on-site for the compliance inspection, the Compliance Officers observed E3 at the facility, providing services to residents. 3. A review of E3's personnel record revealed documentation of a valid FPCC dated prior to E3's date of hire. However, E3's personnel record did not include documentation of the facility's verification of E3's FPCC. 4. In an interview, E4 acknowledged that E3's FPCC card was not verified, and the governing authority failed to ensure compliance with A.R.S. § 36-411(C)(2).”

“Based on documentation review, record review, and interview, the manager failed to ensure that a caregiver provided evidence of freedom from infectious tuberculosis (TB) as specified in R9-10-113, for one of three personnel sampled. The deficient practice posed a potential illness risk to residents. Findings include: 1. R9-10-113.A states, "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, 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)..." 2. A review of the Centers for Disease Control and Prevention website revealed a web page titled "Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005." The web page stated, "If TST (Mantoux Skin T est) is used for baseline testing, two-step testing is recommended for HCWs (Health Care Workers) whose initial TST results are negative. If the first-step TST result is negative, the second-step TST should be administered 1-3 weeks after the first TST result was read." 3. A review of E3's personnel record revealed two negative TB skin tests that were less than 12 months old; however, this documentation was not completed before E3 began providing services at the facility. Based on E3’s date of hire, this documentation was required. 4. In an interview, E4 reported E4 was unaware of the new TB policies as specified in R9-10-113. E4 acknowledged E3 did not provide evidence of freedom from infectious TB as specified in R9-10-113.”

“Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's disaster drill documentation revealed documentation of drills on the following dates: December 30, 2024; September 30, 2024; June 30, 2024; and March 30, 2024. However, the drills were all conducted during the 7: 00 AM - 7:00 PM shift. 2. In an interview, E4 reported the facility operated two staff shifts, 7:00 AM - 7:00 PM and 7:00 PM - 7:00 AM. E4 acknowledged a disaster drill was not conducted on each shift at least once every three months and documented.”