Facility Evaluation Report

At approximately 2:20PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection. LPA met with Executive Director (ED), Jessica Graham, and discussed the purpose of the visit.

LPA returned to the facility for the purpose of amending a document from a visit dated 10/17/2023. This document requires amending due to the use of the improper civil penalty form. LPA is also requesting additional documentation from an incident that occurred 10/14/2023 and was received by CCL on 10/16/2023. LPA previously followed up on this incident in report dated 10/17/2023.

ED updated LPA on th e SOC341 (Suspected Dependent Adult/ Elder Abuse) that was received by CCL on 10/16/2023 and was previously discussed on original report on 10/17/2023. LPA and ED discussed the incident and confirmed that there were not any witnesses to the incident. ED has not yet received the police report despite making multiple attempts to contact them. Per conversation with ED, outside caregiver returned to facility the day following the incident but was promptly removed from the facility grounds and has not returned to facility since.

LPA received documentation on residents care manager, chart notes following the incident, and The Bluffs Requirements for Private Duty Attendants (outside caregiver did not complete required portion of form). ED was unable to locate at time of meeting the internal investigation documentation but confirmed that LPA will receive them via email by the end of the week (between 11/27-12/01).

LPA is requesting the following documents by 12/01/2023

Any internal investigation documents on outside agency caregiver