1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32 | Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 10/28/2023. The facility is approved for a capacity of 6 Non- Ambulatory of which 1 may be bedridden, and Hospice approved for 3 residents.
Staffing: The facility employes 5 staff and 3 Administrators. Staff records are kept confidential. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed had current 1st Aid/CPR for 5 staff, 3 back up staff out of 8 did not have current certificates on file, Administrator stated all staff renewed and will send 3 staffs current certificates to LPA and staff will not work in facility till certificates are renewed. Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions on file. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator's Certificates expire 11/22/2024, 02/21/2025 and 1 is currently pending renewal, LPA verified 1 Administrator on the pending list with CCL.
Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for 2023 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 8 hours of medication training. Trainer met the requirements to train staff. Initial staff 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 1 resident was missing results page, Administrator requested to have the paperwork with results faxed over and will provide a copy to LPA, 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.
Continued 809-C |