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32 | Medication- 2 residents medication were checked at random. the Licensee has adopted a hybrid of Alcomy and a physical log. 1 of 2 residents had a weekend away, where the drugs went into their custody while they were away from the facility. LPA asked for supportive documentation and the notes section details when the client left and came back but not a distribution of the medication. PRN/Refusal/Destruction documentation has some documentation but it is sparse(2019,2020, 2022), LPA was given the explanation by the administrator that not a lot of participants make use of their PRNs. LPA's gave guidance recommending a staff wide training to refresh on t22 documentation procedure, and the facility's own internal documentation procedure, particularly if they are moving towards a fully electronic record.
Fire extinguishers are dated 11/4/26. Smoke/CO detectors are functional.
Client files- 5 client files were reviewed for health screenings, recent medical assessments, signed admission agreements, and IPPs. files are present and up to date. LPA noted the daily logs for the clients are very similar from client to client and day to day, LPA gave guidance the daily notes log, t22 is most interested in changes in condition away from baseline(physical/emotional/etc), and residents participation with activities/what the activities for that day (physical/group interaction/etc).
Staff files- 5 staff files were reviewed for health screenings, most recent training's, topics of original training, statements of qualification, and first aid/cpr. files are present and up to date. LPA gave guidance that annual staff training's are also opportunities to explore how to better serve the needs of the clients. If a client ends up with a restricted condition (wounds, tubes, injections, etc.), part of the care plan is that staff need 4 hours annual training related to that condition on top of the normal required topics and hours.
Administrator files- LPA reviewed the required postings, the facility license, the administrator certificate, the evacuation plan, and the infection control plan. The Administrator informed the LPA they were going to change the ownership structure from a sole proprietorship to a LLC, LPA asked for a LIC 200 with the updates to be sent to his email: noel.wolfpetersen@dss.ca.gov
P+I- 2 residents P+I were checked at random, one had a balance that was wrong but in the favor of the client by 10$, LPA gave guidance that the operator should self audit the records.
Client interviews- 5 clients were interviewed, all report no complaints about thier care.
Staff interviews- 1 staff was interviewed, able to describe the abuse reporting policy, personal rights of clients, and the way information is passed from one shift to the next.
no citations were issued, A copy of the report was read and left with the administrator. exit interview was conducted. |