Douglas A. Ducey, Governor Jami Snyder, Director Sent via electronic mail January 7, 2019 Perry Petrilli QIDP/Director of Social Services, ICF-ID Hacienda HealthCare 1402 E. South Mountain Ave Phoenix, AZ 85042 Re: Corrective Action Dear Mr. Petrilli, The Arizona Health Care Cost Containment System (AHCCCS), Division of Health Care Management (DHCM), on behalf of the agency and its contracted Managed Care Organizations (MCOs), is issuing this joint Corrective Action letter to Hacienda due to an onsite review conducted on or about December 31, 2018, as a result of a reported incident. AHCCCS conducted an onsite review and determined there are immediate health and safety concerns pursuant to Hacienda’s qualifications to provide services to AHCCCS members. Based on Quality of Care Review, AHCCCS has determined that the health and/or welfare of one or more AHCCCS members is endangered and immediate Corrective Action is required due to substantial and critical failures of Hacienda to safeguard member’s safety and ensure quality of services, pursuant to Paragraph 7 of the AHCCCS Provider Participation Agreement executed on or about September 30, 2013, and September 27, 2013, (the “Agreement”). Paragraph 7 states, “The Provider shall comply with all AHCCCS and/or Contractor Provider Manuals and Policy Guidelines, including the AHCCCS minimal Subcontract provision found on the AHCCCS public website and any amendments thereto, all of which are incorporated by reference in this Agreement.” Specific AHCCCS policy violations include Medical Policy Manual (AMPM) Chapters 400 and 900, Arizona Administrative Regulations Title 9 Chapter 28 Article 5, 42 CFR 438.330(a)(1) and (e), 42 CFR 438.330(a)(3), 42 CFR 438.330(e)(1), and 42 CFR 438.330(e)(2). In addition to the actions listed in Hacienda’s preliminary action plan letter submitted to the Arizona Department of Health Services (ADHS), Licensing Branch Chief, Ms. McCanna, on 12/31/2018, and in addition to the AHCCCS Bed Hold Suspension, issued by the AHCCCS Office of Inspector General (OIG), effective 1/3/2019 and in effect until further notice from AHCCCS, AHCCCS and its MCO contractors require the following actions: 801 East Jefferson St., MD 1600, Phoenix AZ 85034 • 602-417-6600 • www.azahcccs.gov Hacienda – Corrective Action Letter January 7, 2019 Page 2 of 4 1. Family/Guardian Notification – a. Submit copies of any and all information, written or oral, regarding what has already been communicated to family/guardians related to this incident. Include case notes or other summaries of verbal communications as well as any hard copy or electronic communication that has been provided. b. General notification needs to occur within one (1) business day of receipt of this letter, informing resident’s families/guardians that a potential sexual assault has occurred on campus. The notification must provide thoughtful consideration to the seriousness and sensitive nature of the reported incident, and should address AHCCCS Chief Medical Officer stipulation that all AHCCCS SNF and ICF members be availed of a current nursing assessment, including: c. Sexually Transmitted Infection testing for all residents (male and female) that includes urine gonorrhea, chlamydia (males and females) and trichomoniasis testing. d. Pregnancy testing for all females of childbearing age/clinically appropriateness; urine pregnancy testing for all females, e. The option of further blood testing for Hepatitis B & C, RPR, & HIV. To this end, Hacienda must develop a standard notification, to include requesting Parent/Guardian consent for the testing. AHCCCS must approve the standard notification in writing prior to distribution. Submit information regarding what has already been communicated by Hacienda to Family/Guardians and the required notification as outlined above to Marie McCabe, Quality Management Manager @azahcccs.gov by close of business January 8, 2019. 2. Fingerprint and DCS Clearance a. All individuals working within the facility must have a current State of Arizona Department of Public Safety Level 1 Fingerprint Clearance Card and have been screened for DCS clearance. b. Submit current fingerprint clearance card and proof of DCS clearance for all current Hacienda staff, contractors, and facilities management personnel. 3. Security Badges a. Submit current protocols for identification of all individuals on campus including employees, contractors and visitors. b. All individuals working on the campus must have a badge that is visible at all times. If photo badges are not currently in use provide in the Action Plan steps to implement photo identification. c. All visitors on campus must have a badge or visitor identification that is visible at all times. 4. Improve Security: a. No propping open of any entry doors. b. Provide security cameras in common rooms and hallways. Add security cameras between ICF and SNF so that access ingress and egress from patient rooms can be Hacienda – Corrective Action Letter January 7, 2019 Page 3 of 4 c. d. e. reviewed. Implement a Visitor policy which includes any visitor hour restrictions; a visitor sign in log, how visitors are monitored; and visitor badge policy that includes a provision that all visitors must wear a badge with the appropriate room # that they are visiting and that it be visible at all times. Hacienda must enforce compliance with visitor signing in and out of the facility and limit access where visitors enter the facility. Any programs offered on site must be monitored to ensure that all volunteers/employees are safe, including work program staff. 5. Monitors - Submit a description of the distinct roles of a Monitor, including the ratio of a Monitor to the number and complexity of members being monitored. a. Monitors must be onsite and have no other duties in addition to the responsibility of monitoring. b. Monitors must all be female until further notice from AHCCCS, and must be employed by a third party/independent from Hacienda Healthcare. c. The common entry point of the campus must be staffed 24 hours a day/seven days per week and ensure all visitors have a valid reason to be onsite. 6. Every 15 minute checks a. Submit description of the “q 15 minute checks” and a listing of what these checks entail. 7. Policy for transporting of members a. Submit a copy of the facility’s current policy on transporting members, including description of the transportation service (employee/owned van vs. transportation vendor). b. Immediately, Hacienda must institute a practice of including two transport personnel for all residents being transported and the personnel must include at least one (1) female staff. 8. Policies for weekly and monthly clinical team ( including CNAs, RNs/LPNs, NPs, PAs and MDs) assessments a. Submit current policies and procedures for weekly and monthly assessments by clinical team with effective dates. Policies should include the following elements: i. Frequency of complete physical evaluations, including abdominal and/or pelvic examination with documentation protocol and any established process to report any newly noted physical finding/condition to supervisor. ii. For female patients with menstruation cycles, monthly monitoring of start and duration of cycle including requirement to report any change to supervisor. 9. Policies for Abuse/Neglect Training a. Submit policy and procedures on employee abuse/neglect training. b. Submit current abuse/neglect training material to AHCCCS. Hacienda -- Currecme Acuun Letter January 7. 2019 page 4 or 4 c. must approve training material prior to the next tmining session. will provide technical assistance. d. Abusdneglecl training must occur on a quarterly basis effective with January 2019 training. 10. Provide the name of Ihe currenl physician and Medical Direclor responsible for the medical care and services of members effective 1/8/2019. 11. Submit the contact information for a single point of contact at Hacienda for communication with the health plans and other stakeholders regarding the ongoing health safety of the members residing in the facility. Unless otherwise noted, submit an Action Plan undressing nu ofthe above 11 actions (0 Marie McCabe @nwhu'cxtgav by 614152 af business Friday January 11, 2011 If you should have any questions, please contact me or 5027 4174122. Sincerely Virginia Ronntree Assistant Directorr DHCM Banner University Health Plan Department of Economic Security/Division of Developmental Disabilities Mercy Care UnitedHealthcare Community Plan 00: Staff