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25 | Licensing Program Analyst (LPA) Sabrina Calzada arrived unannounced to conduct a quarterly on-site case management inspection pursuant to a Stipulation and Waiver and Order adopted on 08/19/2022. LPA met with Kylie Whitaker, Health Services Director, and explained purpose of inspection. LPA spoke with Administrator, Andrea Armstrong, by phone, at the start of the inspection.
Prior to initiating today's inspection, LPA completed required COVID-19 protocols LPA was screened per Covid-19 precautionary measures upon entering the facility and was wearing a surgical mask.
During today's inspection, LPA reviewed the "Compliance Binder" and observed it to be organized and to contain tab dividers for each requirement as set forth in in the Stipulation. LPA also observed monthly training by an RN, monthly medication room training and weekly staff training to be current. LPA observed a variety of care giving topics to have been presented by both in-house and outside company instructors. LPA observed documentation for quarterly medication audit on file also. . Additionally, the facility emailed LPA documentation of the medication audits earlier this month.
LPA observed additional current documentation for weekly meetings related to high risk residents and daily door alarm checks. LPA observed a copy of the Stipulation to now be filed in the "Compliance Binder" for ease of verifying information at quarterly inspections.
There are no citations issued on this report.
Exit interview. Copy of report provided to Health and Services Director. |