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25 | Licensing Program Analyst (LPA) Victoria Willis and Caitlynn Felias arrived unannounced, to conduct an Annual Required inspection and met with Licensee, Martha Lovejoy who had to leave but gave permission for back-up Administrator, Linda Ruhaka to sign report. The inspection is focused on the Infection Control procedures and practices of this facility.
Upon arrival, LPAs observed Covid-19 posters on the front door and entryway. LPAs were greeted by caregiver on duty but LPAs were not screened for Covid-19 symptoms. LPAs initiated a walk-through of the facility around 9:55 am and observed the following: Facility has COVID-19 posters throughout that includes hand washing signs in bathroom. Hand sanitizer is located throughout common areas of the facility. Other hand-washing supplies were also observed in bathrooms. LPA confirmed with Licensee that they are conducting vaccine verification for visitors per Provider Information Notice (PIN) 21-40-ASC. Facility was a comfortable temperature and exits were free from obstructions. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected once per day according to Licensee. Facility maintains documentation of staff and resident temperatures, however temperatures are not always checked daily. LPA confirmed that facility is following the staff vaccination guidance per PIN 21-44-ASC. Licensee has been requested to review PIN 21-49-ASC regarding updated guidance on communal dining, group activities, entertainment, non-essential services, and transportation.
Facility has a designated visitation area outside and is allowing for inside visitation after vaccination verification or proof of a negative test within 72 hours, per current CCL guidance. Visitors are required to wear a mask while in the facility. Staff have completed some PPE training but have not been N95 fit tested. LPA and Licensee discussed options for having staff fit tested and LPA suggested additional training on infection control and for Licensee to document training received for donning and doffing of Personal Protective Equipment.
Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has a 30 day supply of PPE including but not limited to masks, gowns and hand sanitizer. LPA suggested additional PPE be obtained including N-95 masks. Facility maintains a 30 day supply of medication.
Licensee and LPA discussed their Emergency Disaster Plan. Fire extinguishers were last serviced November 2019. Licensee called and set an appointment for service during this inspection. Smoke alarms throughout the facility and Carbon Monoxide detector were tested and operational.
No deficiencies cited during this inspection. |