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25 | Licensing Program Analyst (LPA) De Leon arrived at 11:00 am to conducted a case management annual continuation visit to the facility above. LPA met Administrator Jennifer Lawrence and explained the purpose of the visit.
Staffing: The facility employes 8 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 random staff files. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. All files were kept up to date with all requirements being met.
Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training, 4 hours of hospice care, postural supports and restricted health condition and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements, PPE and Quarterly Disaster Drills. Staff handling medications had required medication training. Trainer met the requirements to train staff. Initial training was kept on file.
Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources for the residents in care. Facility does submit incident reports to the department when required.
Incidental Medical & Dental: The facility has a medication cabinets in the hallway if the facility that is kept locked. Facility provides transportation to medical and dental appointments when needed. The medications records were reviewed and all residents in care had a Medication Administration Record (MAR) and a Centrally Stored Medication Destruction Record (CSMDR). LPA inspected medication cupboards for all prescription and PRN medications and Doctors orders. No medications labels were altered. LPA chose 1 random residents medications to review and all requirements were met and followed. The facility has a locked box in refrigerator for required medication and an ice chest with ice packs to keep cold for emergency use. The facility has a red sharps container for disposal of syringes. Medications destructed by Administrator and 1 other person.
Exit interview conducted, No deficiencies cited, copy of report printed for Administrator. |