Facility Evaluation Report

Licensing Program Analysts (LPAs) Tao and Reyes conducted an unannounced initial case management visit regarding a Health and Safety check of the facility regarding a hospice resident#1 (R1). LPAs met with Administrator, Tokie and explained the reason of the visit.

According to the incident report dated 3/7/24, R1 admitted to hospice on 9/3/23 and became bedridden on 3/6/24. Per investigation, Hospice stated R1 is bed bounded and the life expectance is less than 14 days. Administrator had contacted fire department for a fire watch during this period of time.

During today's visit, LPA interviewed administrator, R1's file was reviewed and obtained the following:

· Resident #1 (R1) facesheet dated 04/25/23

· Unusual incident report, dated 03/07/24

· R1's Vitas Healthcare plan of care, dated 3/8/24

Administrator stated she provide updates about R1 via incident report / death report. Exit interview was conducted and a copy of LIC 809 Report was provided to administrator.