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32 | Operational Requirements: The facility has a current plan of operation 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 4/29/2024. The facility is approved for a capacity of 6. The fire clearance is granted for 6 Non-Ambulatory 2 of which may be bedridden. Hospice is approved for 6.
Staffing: The facility currently employes 4 full time staff, 5 part time staff and 2 Administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Fingerprint clearance and education requirements. Administrator Certificate expires March 22, 2024.
Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training completed for all subjects/topics and hours for 2023.
Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Facility does submit incident reports to the department when required. LPA reviewed 5 resident files for signed Admission Agreements, Personal Rights, Safeguard for property and valuables, LIC. 602A Physicians report, Appraisals Needs and Services Plan, Emergency and ID forms, all forms were legible and records are kept confidential.
Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables and plenty extra, to meet the food service requirement. The freezer is kept at 0 degrees and the refrigeration is kept at 40 degrees or lower. All food is covered, stored and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices.
Incidental Medical Services: Facility provides assistance in arranging transportation to medical and dental appointments when needed. Residents have on-call Doctor that visits facility. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). LPA reviewed residents’ medications, no labels were altered, no medications were expired and all medications were kept in their original containers.
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