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25 | Licensing Program Analyst (LPA) Victoria Willis arrived unannounced to conduct an Annual Required inspection and met with Licensee/Administrator, Kristi Shehan. The inspection is focused on the Infection Control procedures and practices of this facility.
Upon arrival, LPA observed a notice on the front door which outlined the facility's visitation and Covid-19 screening policy. Upon entry into the facility LPA's temperature was taken by the Licensee and LPA was asked to fill out a questionnaire with standard Covid-19 screening questions. LPA initiated a walk-through of the facility around 9:35pm and observed the following: Facility has COVID-19 posters throughout that includes hand washing and cough etiquette signs in bathroom. Hand sanitizer is located throughout common areas of the facility. Other hand-washing supplies were also observed in bathroom. 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 three times per day, on each shift. Facility maintains documentation of staff and resident daily temperatures.
Facility has a designated visitation area outside. Visitation is allowed inside the facility after vaccination verification or proof of a negative test within 72 hours, per current CCL guidance. Staff have completed PPE training and have been N95 fit tested.
Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns and hand sanitizer. Facility maintains a 30 day supply of medication.
Licensee and LPA discussed their Emergency Disaster Plan. Fire extinguishers have been serviced within the last year. Facility recently had an inspection by the local fire department. No issues noted.
LPA requested the updated lease from Licensee.
No deficiencies cited during this inspection. |