B S D Home Care LLC.

“Based on documentation review, record review, and interview, the assisted living home failed to maintain a standardized form for two of two residents that included the information in 36-420.04(A)(1-9), for two of two residents sampled. Findings include: 1. A.R.S. 36-420.04.A states, "A. An assisted living center or assisted living home that contacts an emergency responder on behalf of a resident shall provide to the emergency responder a written document that includes all of the following: 1. The reason or reasons the emergency responder was requested on behalf of the resident. 2. Whether the resident receives medication services and, if the resident has provided this information to the assisted living center or assisted living home, a list of all the resident's prescription and over-the-counter medications, their dosages and how frequently they are administered. 3. The name, address and telephone number of the resident's current pharmacy. 4. A list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive. 5. The name and contact information for the resident's primary care physician and power of attorney or authorized representative. 6. Basic information about the resident's physical and mental conditions and basic medical history, such as having diabetes or a pacemaker or experiencing frequent falls or cardiovascular and cerebrovascular events, as well as dates of recent episodes, if known. 7. The point-of-contact information for the assisted living center or assisted living home, including the telephone number, if available, cell phone number and email address. A point of contact must be available to respond to questions regarding the information provided twenty-four hours a day, seven days a week. 8. A copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge. This paragraph does not preclude a resident from revoking the resident's health insurance portability and Accountability Act release authorization. 9. A copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. This paragraph does not preclude a resident from revoking or modifying the resident's advance directives."    2.  A review of R1’s medical record revealed a standardized emergency medical form that was missing the following: the name, address and telephone number of the resident's current pharmacy, a list of any known allergies to any medications, additives, preservatives or materials like latex or adhesive, a copy of the resident's health insurance portability and accountability act release authorizing a receiving hospital to communicate with the assisted living center or assisted living home to plan for the resident's discharge, and a copy of the resident's advance directives, if any, on file at the assisted living center or assisted living home. 3. A review of R2’s medical records revealed no documentation that included the aforementioned information. 4. In an exit interview, the findings were discussed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the chief administrative officer failed to implement tuberculosis (TB) infection control activities including annually providing training and education related to recognizing the signs and symptoms of TB, for two of three sampled employees. The deficient practice posed a potential TB exposure risk to residents. Findings include: 1. A review of E1 and E2's personnel records revealed no documentation of education related to recognizing the signs and symptoms of tuberculosis. Based on E1's and E2's dates of hire, this documentation was required. 2. In an interview, E1 reported not having training related to recognizing the signs and symptoms of tuberculosis. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on document review and interview, the manager failed to ensure that a plan was established, documented, and implemented for an ongoing quality management program that included: a method to identify, document, and evaluate incidents, a method to collect data to evaluate services provided to residents, a method to evaluate the data collected to identify a concern about the delivery of services related to resident care, a method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care, and the frequency of submitting a documented report required in subsection (2) to the governing authority.The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided.  Findings include: 1. A review of the facility's documents revealed no quality management program documentation. 2. A review of the facility's policies and procedures revealed the following policies: A policy titled "Quality Management." This policy stated," A manager shall ensure that: 1. A plan is established, documented, and implemented for an ongoing quality management program that, at a minimum, includes: a. A method to identify, document, and evaluate incidents; b. A method to collect data to evaluate services provided to residents. c. A method to evaluate the data collected to identify a concern about the delivery of services related to resident care; d. A method to make changes or take action as a result of the identification of a concern about the delivery of services related to resident care; and e. The frequency of submitting a documented report required in subsection (2) to the governing authority. 2.A documented report is submitted to the governing authority that includes: a. An identification of each concern about the delivery of services related to resident care, and b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care; and 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. A policy titled Quality and Risk Management." This policy stated 1. The manager shall be responsible for establishing, maintaining, and implementing a continuous quality improvement system/plan. 2. All employees shall: i. be involved in CQI; ii. receive orientation and training related to CQI; and iii. bear a responsibility for CQI. 3. Clients, families, and employees shall be involved in decision-making, regarding quality improvement activities. 4. When issues are identified, employees shall be consulted, and corrective action shall be taken to resolve the problem or issue. 5. Regular staff meetings shall be held and information shall be shared to ensure that an acceptable level of quality control is maintained." 3. A review of the document request form revealed that the Compliance Officer requested the facility's quality management documents at 9:35 am. 4. In an interview, E1 reported the facility had documentation of a quality management program, but was unable to find it. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.”

“Based on documentation review, record review, and interview, the manager failed to ensure that a resident's medical record contained documentation of the resident's notification of the availability of vaccination for influenza (flu) and pneumonia, according to A.R.S. § 36-406(1)(d), for one of two residents sampled. The deficient practice posed a potential illness risk to residents. Findings include:  1. A.R.S. § 36-406(1)(d) states, "The department shall: Require as a condition of licensure that nursing care institutions and assisted living facilities make vaccinations for influenza and pneumonia available to residents on site on a yearly basis." 2. A review of R1's medical record included documentation of R1's notification of the availability of vaccinations for flu and pneumonia for 2021, but no documentation for 2022 through 2025. Based on R1's date of admission, this documentation was required. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 4. This is a repeat deficiency from the compliance inspection conducted on January 27, 2023.”

“Based on documentation review, observation, and interview, the manager failed to ensure that there was a means of exiting the facility that monitored or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include:  1. A review of Department documentation revealed the facility was licensed to provide directed care services.  2. During an environmental tour of the facility, the Compliance Officers observed the following: The front door was equipped with an alert; however, the alert was not tuned off at the time of inspection; The back door was equipped with an alert; however, the alert was turned off at the time of inspection; The exits from the facility were not monitored at the time of inspection. 3. In an exit interview, the findings were reviewed with E1, and no additional information was provided”