Emergency and Disaster Response Plan

Use the related family guide: Emergency planning →

The provider was out of compliance with this rule by not ensuring the emergency and disaster response plan addressed all of the response plans required by the rule. During the third follow up inspection, the licensor requested the emergency and disaster response plan that included the instructions on how to recruit additional help, supplies, and equipment to meet the resident's needs after an emergency or disaster; delivery of essential care and services if additional persons were housed in the facility during any emergency; and delivery of essential care and services to facility occupants if personnel were reduced by an emergency. The owner did not have the response plans included in the emergency and disaster response plan. This is a repeat non-compliance from the re-licensure inspection, dated 1/8/2024, and the follow-up inspections, dated 3/13/2024 and 4/15/2024.

Civil money penalty amount shown by Utah: $400.00. Utah describes a civil money penalty as a department fine; the amount alone is not a quality or safety score. Read Utah's guidance ↗

Correction action: On 7/9/2024, the licensor verified that the administrator added all the requirements to the facilities Emergency and Disaster Response Plan as stated in rule.

Emergency and Disaster Response Plan

Use the related family guide: Emergency planning →

The provider was out of compliance with this rule by not ensuring the emergency and disaster response plan addressed all of the response plans required by the rule. During the second follow up inspection, the licensor requested the emergency and disaster response plan that included the instructions on how to recruit additional help, supplies, and equipment to meet the resident's needs after an emergency or disaster; delivery of essential care and services if additional persons were housed in the facility during any emergency; and delivery of essential care and services to facility occupants if personnel were reduced by an emergency. The owner did not have the response plans included in the emergency and disaster response plan.

Civil money penalty amount shown by Utah: $200.00. Utah describes a civil money penalty as a department fine; the amount alone is not a quality or safety score. Read Utah's guidance ↗

Correction action: On 7/9/2024, the licensor verified that the administrator added all the requirements to the facilities Emergency and Disaster Response Plan as stated in rule.

In-service Training

Use the related family guide: Staff training and coverage →

The provider was out of compliance with this rule by not ensuring employees received documented in-service training that was tailored to annually include subjects relevant to the employee's job responsibilities. During the inspection, five (5) employees were not documented to have received all required annual in-service training relevant to their job responsibilities.

Civil money penalty amount shown by Utah: $200.00. Utah describes a civil money penalty as a department fine; the amount alone is not a quality or safety score. Read Utah's guidance ↗

Correction action: On 5/20/2024, the licensor verified employees received documented in-service training that was tailored to annually include subjects relevant to the employee's job responsibilities, as stated in rule.

Update Status within 5 working days

Use the related family guide: Staff eligibility and identification →

The provider was out of compliance with this rule by not ensuring the Direct Access Clearance System (DACS) reflected the current status of a covered individual within 5 working days of engagement. During the inspection, 1 current employee was observed to be linked to the facility in DACS after 5 days of engagement.

Correction action: On 4/15/2024, the licensor verified the provider ensured the Direct Access Clearance System reflected the current status of covered providers within 5 working days of engagement, as stated in rule.

Emergency and Disaster Response Plan

Use the related family guide: Emergency planning →

The provider was out of compliance with this rule by not ensuring the emergency and disaster response plan addressed all of the response plans required by the rule. During the follow up inspection, the licensor requested the emergency and disaster response plan that included the instructions on how to recruit additional help, supplies, and equipment to meet the resident's needs after an emergency or disaster; delivery of essential care and services if additional persons were housed in the facility during any emergency; and delivery of essential care and services to facility occupants if personnel were reduced by an emergency. The owner did not have the response plans included in the emergency and disaster response plan.

Correction action: On 7/9/2024, the licensor verified that the administrator added all the requirements to the facilities Emergency and Disaster Response Plan as stated in rule.

Medication error incorporated into facility qio process

Use the related family guide: Medication administration → · Compare the exact-label public finding cohort →

The provider was out of compliance with this rule by not incorporating medication errors into the facility's quality improvement process. During the inspection, the quality assurance meeting minutes for the previous quarter was reviewed. The facility was not observed to have incorporated medication errors into the facility's quality improvement process.

Correction action: On 4/15/2024, the licensor verified the provider incorporated medication errors into the facility's quality improvement plan, as stated in rule.

Secure Unit Admission Agreement

Use the related family guide: Admission and resident assessment →

The provider was out of compliance with this rule by not ensuring that each resident admitted to a secure unit had an admission agreement that indicated placement in the secure unit. During the inspection, 1 secure unit resident file was reviewed and did not contain an admission agreement that indicated placement in the secure unit.

Correction action: On 3/13/2024, the licensor verified that the administrator obtained a written admission agreement that indicated placement in a secured unit, as stated in rule.

Employee Health Inventory

The provider was out of compliance with this rule by not ensuring 4 employees were skin-tested for tuberculosis within 2 weeks of initial hiring. During the inspection, a sample of employee files were reviewed and 4 employees did not have documentation of a tuberculosis skin-test within 2 weeks of initial hiring.

Correction action: On 4/15/2024, the licensor verified employees were skin tested for tuberculosis within 2 weeks of initial hiring, as stated in rule.

In-service Training

Use the related family guide: Staff training and coverage →

The provider was out of compliance with this rule by not ensuring employees received documented in-service training that tailored the training to annually include subjects relevant to the employee's job responsibilities. During the inspection, 7 employees were not documented to have received all required annual in-service training.

Correction action: On 5/20/2024, the licensor verified employees received documented in-service training that was tailored to annually include subjects relevant to the employee's job responsibilities, as stated in rule.

Residents Rights

Use the related family guide: Resident rights →

The provider was out of compliance with this rule by not ensuring residents were free from chemical restraint. During the inspection, 1 resident was found to not be free from chemical restraint.

Civil money penalty amount shown by Utah: $200.00. Utah describes a civil money penalty as a department fine; the amount alone is not a quality or safety score. Read Utah's guidance ↗

Correction action: On 3/13/2024, the licensor verified that residents were free from chemical restraints and that the facility licensed health care professional was giving prior approval prior to the administration of PRN medications, as stated in rule.