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25 | Licensing Program Analyst (LPA), Melchisedeck Augustin conducted a Plan of Correction (POC) visit and met with Center Director, Biane Isbeih to follow up on several outstanding POC. On 05/26/23, the facility was cited because S2 was missing evidence of negative TB clearance, and S1-S5’s records did not contain required immunization records, and C6 & C7’s inhaler and EpiPen were expired. The facility's POC due date was on 06/05/23 and the Department provided the facility with multiple reminders to submit the outstanding POC, however; the facility had not submitted its POC.
During today's visit, LPA reviewed five staff (S1-S5) records at 9:47am which revealed S2 was missing evidence of negative TB clearance, S3 and S5's records did not contain proof of immunity against Measles. According to CD, S2 was actively working on obtaining evidence of negative TB clearance, however; S3 had not provided CD with the required immunization record after CD requested the record from the staff. CD requested for the Department to provide the facility with an extension to obtain S2's evidence of negative TB clearance and there was indication that CD made some attempts to obtain updated medication for C6 & C7, and CD stated she would obtain all required immunization records prior to staff working at the facility. The Department is extending the facility's POC due date and the facility's new POC due date is 06/30/23. A civil penalty of $1100 is being assessed because the facility did not ensure S3 obtained her immunization record prior to working and the facility did not clear or comply with the POC.
A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100. Exit interview conducted and report was reviewed with the Center Director. Appeal Rights were provided.
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