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COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and
good condition. At the time of the visit, common seating area and dining room furniture was
observed to be in good condition. The fireplace in the living room was properly screened. The outdoor area is equipped with furniture for clients' use. There were no bodies of water noted. Cleaning chemicals and laundry supplies are stored in a locked cabinet in the garage.
RECORD REVIEW: At 10:45 a.m., a review of facility files was initiated. Facility records are stored in the office room and hallway closet. The LPA observed documentation of Infection Control, and last Disaster drill (conducted on 08/22/2024). The LPA obtained Client Roster, and Staff Roster. The LPA reviewed five(5) out of six (6) client files and five (5) out of fifteen (15) staff files. The home did not have an updated Emergency and Disaster Plan, otherwise all documents reviewed appeared complete and current. The LPA advised the Administrator client files should be locked to ensure their privacy.
Medications: Medications review began at 11:39 a.m. The LPA reviewed medications for two (2) clients. Medications are centrally stored and locked in locked boxes in a the kitchen cabinet; medications are labeled and checked for expiration dates. Medications are documented on the centrally stored medications and destruction record (CSMDR). Expiration dates on the medication bubble packs did not match the expiration dates on the CSMDR, however the CSMDR's are generated and provided by the pharmacy. The LPA discussed best practices with the Administrator to always review and correct CSMDR that's provided by the pharmacy to ensure it's accurate. During C2's audit, the LPA observed two (2) medications indicated as noon medications in the prescription label, however at noon the medications were still in the pack, and the client is currently at day program. Upon observation, the Administrator stated that the medications are given at 2 p.m. The administrator called the pharmacy tech who advised the LPA that the medications are able to be given at 2pm without any concern.
Interviews: Five (5) out of six (6) clients were at their day program. The client at the facility is non-verbal. The LPA interviewed two (2) staff. There were no concerns voiced.
No citations were issued during today’s visit. Exit interview conducted. A copy of the report was provided. |