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25 | On this day Licensing Program Analysts (LPA) Jaime Vado conducted an unannounced infection control annual inspection visit. LPA met with facility administrator and let her know the purpose of today's visit. Upon entry LPA had temperature taken and answered COVID protocol questions as well as signing the visitor log book.
LPA toured the physical plant inside and out. There are no accessible bodies of water or fire safety hazards observed. COVID postings and hand washing signs are present inside the facility on both floors in hallways and doors. Hand sanitizer is observed as readily available through out the facility. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Medication room is observed as in order and door is locked with additional locks in place for narcotics and other items in the medication room. First aid kit is observed as in place in medication room. Additional first aid kit is located in the kitchen. Toilet and bathing facilities are equipped with grab bars and non-slip mats. Liquid soap is available. Paper towels are present for resident use. Water temperature is taken on lower level common bathroom at 108F. Laundry machines and dryers are observed as functioning. Emergency food supply, dry goods, and perishables are observed as in place. Communal dining room is observed with social distanced tables. 2 residents per table with a transparent screen on the tables as a protective barrier between residents sitting. Fire panel observed as being inspected on 3/22/22. Fire extinguishers are charged ready for use last fully stamp inspected on 12/2022.
Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Medications, toxins are stored appropriately and inaccessible to clients. LPA reviewed training records and they are current. LPA sampled staff first aid cards and training records and they are current. Resident temperature logs and staff logs are current. All staff are vaccinated. Residents are vaccinated with the exception of 2 and an additional 2 are not fully boosted. Facility is continuing with satellite testing of 25% and those that are not vaccinated or fully boosted are tested weekly. Facility PPE supplies are observed as in place.
A disaster and mass casualty plan is present and current. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been finger print cleared and associated to the facility. Administrator certificate is viewed as current expiring 6/30/2023. Mitigation plan is reviewed with the administrator and is current. Infection control plan is current.
LPA received the following updated forms during today's inspection:
• Copy of administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E
Report is reviewed with administrator. No deficiencies cited today. |