Hummingbird Manor #2.

“Based on documentation review, record review, and interview, the health care institution's chief administrative officer failed to ensure the health care institution documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f.   Findings include:   1. A review of facility documentation revealed a tuberculosis policy and procedure dated January 9, 2023. The policy stated, “The manager will provide on an annual basis training and education related to recognizing the signs and symptoms of tuberculosis to employee, volunteer, or caregivers employed by or providing volunteer services for this assisted living facility,” and also stated, “The manager will on an annual basis assess this assisted living facilities risk of exposure to infectious tuberculosis. Documentation of this risk assessment will be updated on an annual basis and maintained with the facility documentation.”   2. A review of E1’s, E2’s and E3’s, personnel records revealed documentation of annual education related to recognizing the signs and symptoms of tuberculosis was not available for review.   3. A review of facility documentation revealed documentation of annually assessing the health care institution's risk of exposure to infectious tuberculosis was not available for review.   4. In an interview, E1 acknowledged the health care institution had not documented, and implemented tuberculosis infection control activities required in R9-10-113.A.2.a-f.   Technical assistance was provided for this rule during the on-site compliance inspection completed on January 24, 2024.”

“Based on record review, documentation review, and interview, the governing authority failed to ensure compliance with A.R.S. § 36-411, for one of three personnel records reviewed. The deficient practice posed a risk if a personnel member was a danger to a vulnerable population.     A.R.S. § 36-411 states:   "A. Except as provided in subsection F of this section, as a condition of licensure or continued licensure of a residential care institution, a nursing care institution or a home health agency and as a condition of employment in a residential care institution, a nursing care institution or a home health agency, employees and owners of residential care institutions, nursing care institutions or home health agencies, contracted persons of residential care institutions, nursing care institutions or home health agencies or volunteers of residential care institutions, nursing care institutions or home health agencies who provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services and who have not been subject to the fingerprinting requirements of a health professional's regulatory board pursuant to title 32 shall have a valid fingerprint clearance card that is issued pursuant to title 41, chapter 12, article 3.1 or shall apply for a fingerprint clearance card within twenty working days after employment or beginning volunteer work or contracted work.   B. A health professional who has complied with the fingerprinting requirements of the health professional's regulatory board as a condition of licensure or certification pursuant to title 32 is not required to submit an additional set of fingerprints to the department of public safety pursuant to this section.   C. Each residential care institution, nursing care institution and home health agency shall make documented, good faith efforts to:   1. Contact previous employers to obtain information or recommendations that may be relevant to a person's fitness to work in a residential care institution, nursing care institution or home health agency.   2. Verify the current status of a person's fingerprint clearance card.   3. Beginning January 1, 2025, verify that a potential employee is not on the adult protective services registry pursuant to section 46-459. If a potential employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency may not hire the potential employee.   4. On or before March 31, 2025, verify that each employee is not on the adult protective services registry pursuant to section 46-459. If an employee is found to be on the adult protective services registry, the residential care institution, nursing care institution or home health agency shall take action to terminate the employment of that employee.   5. Beginning March 31, 2025, annually reverify that each employee is not on the adult protective services registry pursuant to section 46-459.   D. An employee, an owner, a contracted person or a volunteer or a facility on behalf of the employee, the owner, the contracted person or the volunteer shall submit a completed application that is provided by the department of public safety within twenty days after the date the person begins work or volunteer service.   E. Except as provided in subsection F of this section, a residential care institution, nursing care institution or home health agency shall not allow an employee to continue employment or a volunteer or contracted person to continue to provide medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services if the person has been denied a fingerprint clearance card pursuant to title 41, chapter 12, article 3.1, has been denied approval pursuant to this section before May 7, 2001 or has had a fingerprint clearance card suspended or revoked.   F. An employee, volunteer or contractor of a residential care institution, nursing care institution or home health agency who is eligible pursuant to section 41-1758.07, subsection C to petition the board of fingerprinting for a good cause exception and who provides documentation of having applied for a good cause exception pursuant to section 41-619.55 but who has not yet received a decision is exempt from the fingerprinting requirements of this section if the person provides medical services, nursing services, behavioral health services, health-related services, home health services or direct supportive services to residents or patients while under the direct visual supervision of an owner or employee who has a valid fingerprint clearance card.   G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety.   H. For the purposes of this section:   1. "Direct supportive services":   (a) Means services other than home health services that provide direct individual care and that are not provided in a common area of a health care institution, including:   (i) Assistance with ambulating, bathing, toileting, grooming, eating and getting in and out of a bed or chair.   (ii) Assistance with self-administration of medication.   (iii) Janitorial, maintenance, housekeeping or other services provided in a resident's room.   (iv) Transportation services, including van services.   (b) Does not include services provided by persons contracted directly by a resident or the resident's family in a health care institution.   2. "Direct visual supervision" means continuous visual oversight of the supervised person that does not require the supervisor to be in a superior organizational role to the person being supervised.   3. "Home health services" has the same meaning prescribed in section 36-151."     Findings include:   1. A review of E3's personnel record revealed E3 had been hired as a caregiver in 2006.   2. A review of E3's personnel record revealed a fingerprint clearance card with a marked expiration date of November 1, 2024.   3. In an interview, E1 acknowledged E3 did not have a current fingerprint clearance card.”