Facility Evaluation Report

Licensing Program Analysts (LPAs) Crystal Colvin and Venus Mixon arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPAs Colvin and Mixon met with Licensee/Administrator Conchita Diata and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Licensee/Administrator Conchita Diata, who LPA Colvin found to be successfully incorporating several aspects of the facility's Mitigation Plan. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towels. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns) which LPA Colvin observed to not be sufficient for a 30-day supply. Licensee/Administrator Conchita Diata informed LPA Colvin that they have been unable to purchase supplies online, which is why they do not have any N95 msks, isolation gowns, or face shields. LPA Colvin will be issuing a TA Advisory Note instead of a deficiency as it is recommended that the facility maintain a 30-day supply of PPE at all times. LPA Colvin will additionally coordinate to have supplies brought to the facility ASAP to ensure they have everything needed on hand in case of a COVID-19 case.

Upon entry of the facility, LPAs observed that facility staff did not take LPAs temperature or have LPAs sign-in on a sign-in sheet. LPA Colvin inquired as to if the facility has the Hospcie Nurses sign in and have their temperature taken by staff, and the Licensee stated that no they do not. LPA Colvin will be issuing a Technical Assistance (TA) Advisory Note instead of a deficiency (for lack of screening & sign in)as it is only a recommendation by the Department at this time for facilities to screen all visitors prior to admitting to facility, as well as utilizing a sing-in sheet. The Licensee was advised to begin incorporating these recommendations as they may become regulations in the future, for which the facility may be cited deficiencies for.