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25 | Licensing Program Analysts (LPA) Kathleen Banrasavong and Licensing Program Manager(LPM) Jazmond Harris arrived unannounced to conduct an annual inspection. Upon arrival LPA was greeted by facility staff and granted entry. LPA began inspection with introduction and visit purpose. Upon arrival LPAs learned that six (6) clients reside at this facility and there are currently two (2) caregivers present and administrator were present. There are 3 bedridden clients, 2 in hospice. The facility has 6 ambulatory, of which 6 may be non-ambulatory, hospice waiver for 6. Acting Administrator, Claire Itchon arrived during the inspection to do the facility tour. There is an Infection Control Plan on file.
Client Records-Incident Reports/Clients RIGHTS INFORMATION/Dental- LPA began review of client records. Six (6) records were reviewed. LPA reviewed for identification and emergency information, admission agreement, medical assessment and TB test results, needs and service plans, placement, functional assessment, centrally stored medication/destruction records, safeguard for personal property/valuables, and personal rights notification.
Personnel Records/Training/and Staffing- LPAs began review of employee records- Two (2) records were reviewed. LPA reviewed employee records for first aid certification, criminal record clearance or an exemption, health screening and TB test results, employee rights, training verification, and current administrator certification; expiration date 05/25/2025.
Food Service- Food prep areas are clean and organized. Food supply meets the requirement of one (1) week supply of nonperishable and two (2) day supply of perishables. Emergency food and water supply is present. There is a locked location for chemicals and sharps in the kitchen.
(Continued on LIC809C) |