Facility Evaluation Report

Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility to deliver findings on an open complaint investigation (#18-AS-20200115104818). LPA Colvin met with Administrator Michael Hall and during LPA Colvin's inspection LPA Colvin observed the following issues which needed to be addressed:

Exceptions and Waivers: LPA Colvin observed that R1 has two Restricted Health Conditions, for which the facility had not requested an Exception from Community Care Licensing (CCL). Deficiency cited.

Training for Restricted Health Condition: LPA Colvin observed that R1 was admitted back to the facility on 10/16/19 with a colostomy. S1 & S2 worked at the facility in December 2019 and January 2020 (on dates while R1 was present) prior to receiving training on care for the colostomy on 1/24/20. Deficiency cited.

Personnel Requirements: LPA Colvin observed that multiple staff members (S1, S2, S3, S4, & S5) worked at the facility (on dates while R1 was present) prior to receiving training on glucose testing. R1 requires assistance with glucose testing. S1, S2, & S3 did not receive training on this until 1/24/20 and S4 & S5 did not have records showing that they had received the training. Deficiency cited.

Responsibility for Providing Care and Supervision: Hospital records show that R1's discharge from the hospital was delayed 2 days due to hospital not being able to reach facility Administrator. Deficiency cited.

Modifications to Needs and Services Plan: LPA Colvin observed that R1 had numerous hospitalizations from October 2019 to January 2020, where his condition had dramatically changed, such as now having two Restricted Health Conditions. R1's Needs and Services Plan was not updated from 10/1/19 until 1/1/20. Deficiency cited.