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25 | Licensing Program Analyst (LPA) Elliott conducted a case management visit to follow up on concerns revealed to Community Care Licensing (CCL) regarding facility surveillance testing and staffing. LPA met with Kimberley Humphrey, Executive Director. LPA was screened for COVID-19 upon arrival. Executive Director indicated they are still waiting for COVID-19 mitigation plan and will request it from Supervisor this afternoon. Executive Director indicated they are actively hiring and surveillance testing is ongoing per CCL requirements. LPA also followed up regarding Plans of Correction (POC)'s from a citation issued on 5/6/2021 related to complaint number 21-AS-20210304083733. LPA determined the following deficiencies are still outstanding:
- 87463 Reappraisal. (c) The licensee shall arrange a meeting with the resident, the resident’s representative, if any, appropriate facility staff,...when there is significant change in the resident’s condition...Administrator agrees to submit a plan to ensure all residents personal service plans reflect current conditions and needs to CCL by POC date of 5/20/2021.
- 87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency within 7 days... Administrator agrees to review regulation and conduct training for all staff on reporting requirements. Signed statement that the regulation was reviewed and sign in sheet for all staff trained to be submitted by POC due date of 5/20/2021.
- 87208 - Plan of Operation: Administrator agrees to submit plan to ensure Falls Management Policy CS-30-14, as well as Clinical Guidelines for Fall Prevention and Management are followed by POC date of 5/20/2021.
LPA and Executive Director agreed plans of correction will be submitted to LPA by 7/15/2021. LPA will e-mail citations to Executive Director. No citations issued for deficiencies at this time. |