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25 | Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual visit at 12:30 p.m. The LPA met with Program Director Martha Shapiro and explained the reason for the visit. There were twelve (12) consumers and four (4) program staff present today. The program currently operates from 10:00 a.m. to 2:00 p.m. The day program was staffed with 1:3 staff to consumer ratios. Temperatures of staff and consumers are taken upon entry into the facility. Consumers and staff are screened upon entry and additional masks and sanitizer is available as needed.
Common Activity Space: The facility had large activity rooms, conference rooms, bathrooms, offices, and a food service area. The LPA did not observe any obstructions or hazards. Furniture and equipment was observed to be in good condition. The delayed egress doors were tested during today's visit and were operational. Fire extinguishers were fully charged and serviced 6/2022. Cleaning supplies were locked inaccessible. Medications: Medications were locked and inaccessible in the medication room. Medications were observed to be stored in its original container, and staff utilized a Medication Administration Record (MAR) for documentation purposes. Activities: Activities are both designed for individual and as a group. The LPA observed staff working with consumers. Food Service: The program serves lunch and two (2) snacks. Restrooms: Restrooms were clean and sanitary and stocked with soap and paper towels. Appropriate hand-washing signs were observed in all bathrooms. Files: At 1:25 p.m., the LPA checked staff associations and identified that all staff were fingerprint cleared and associated to this location.
Infection Control: There was a central entry point for symptom screening and temperature checks. The LPA was appropriately screened upon entry. Staff were wearing appropriate face coverings. Infection Control signs were observed throughout the facility. Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility keeps record of staff vaccinations. The facility's procedures as it pertains to infection control are adequate.
No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
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