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32 | Admin files were reviewed, including but not limited to: admin certificate(expiring 5.8.26), LIC 500(Staff schedule has 17 hours of coverage week days, week nights seems to have a 7 hour vacancy from 11pm-6am, staff schedule has 9 hours of coverage on the weekends, weekends seem to have a 15 hour vacancy from 3pm-6am), Aministrator provided there she and her husband are live in monday to friday, 1 additional staff is to be hired, LPA gave guidance night supervision requires on call on premises staff, and staff should have 5 hours of break between shift. LIC 9020(client Roster), Hiv Training, Fire drill record, Emergency preparedness, Infection control Plan, required posters(Personal rights, Ombudsman, facility license, facility sketch), and Plan of Op(control of the property via grant deed, surety bond(no bond) and liability insurance) are up to date and present.
Client files were reviewed, including but not limiting to: recent medical assessments, admission agreements, functional capability assessments, and needs and services plans. Client exhibt restricted conditions: o2 administration due to copd, insulin dependant diabedies, facility does not have these services covered in ammendments toPlan of Op or having adequate trainings(4 hours per) for staff. Lpa gave guidance that more of the yearly training should be devoted to the following topics: wandering, diebetes, 02 administration. Needs and services plans read as the same for folks and are unfilled out in some portions. LPA gave guidance to contextualize needs and services plan to the specific needs of the clients. Admission agreement contains prohibited terms(refund conditions only allow for 15 days of basic services after the death of the resident.) LPA gave guidance that terms meet admission guidlines. LPA is requesting a copy of the updated admission agreement and the needs and services plans 2/5/26.
Staff files were reviewed, including but not limited to: first aid training, continuing education, and criminal background check, health screening. Most annual training records are due for January, some records are out of date by a few days. Staff training is inadequate for restricted condition care, staff should have 4 hours annually for each restricted condition. LPA gave guidance to seek a licensed medical service provider outside her current employ to run an inservice for the restricted condition care for all employees.
no citation was issued, a copy of the report was given. Exit interview was conducted. |