Facility Evaluation Report

Licensing Program Analyst (LPA) Jennifer Semin arrived at the facility unannounced after completing a COVID-19 Risk Assessment Screening for the facility via telephone. LPA met with administrator William Moquette and advised him of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only.

LPA went over COVID-19 best practices for infection control and prevention with Mr. Moquette who is successfully incorporating the facility's Mitigation Plan. Clients have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA observed minimal signs posted however administrator and staff discuss all the information in these signs with the clients daily regarding cough etiquette, proper hand washing procedure and social distancing. All emergency contact information for local fire department has been updated.

LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was located at the central entry point for convenience. LPA observed several storage areas for storing all PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant and hand sanitizer supply and is inaccessible to clients.

LPA inquired as to if staff have been fit tested for N95 masks, and Mr. Moquette stated their staff have not been fit tested yet. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive clients, and N95 masks only needing to be worn when a client is COVID-19 positive or under observation while awaiting test results. Additionally, most of the clients have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19. LPA provided Mr. Moquette with the Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.

An exit interview was conducted, and this report was discussed and provided to Mr. Moquette along with a copy of PIN 21-10-ASC and LIC9102 TA Advisory Note.