Facility Evaluation Report

On 6-15-23 at 11:00am, regional office conducted an informal meeting with facility to discuss recent citations issued and additional concerns. This meeting was held virtually via Teams Meeting. Present at the meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, Licensing Program Analyst Jennifer Fain, and Administrator Beatrice Clark. Topics in this meeting included but not limited to the following: (1) Incidental Medical care (2) Maintenance and Operation, (3) Exceptions for Restricted and Prohibited health conditions regarding presence of wounds and catheter care, (4) Care and Supervision regarding wounds and (5) Staffing levels

LPAs Bilger and Fain, and LPM King discussed with administrator citations issued between 11-16-22 and 4-18-23 and the associated plans of correction going forward. Administrator stated medication are audited by her to ensure accuracy and a plan going forward will be implemented to ensure medication listed on log sheets match physicians’ orders. Administrator further stated she is currently working more than 40 hours per week at facility and two staff are on duty at all times. In regards to catheter care, Administrator stated she is now aware of the need for exceptions for catheter care and other restricted and prohibited conditions

The following are the results from complaint allegations previously issued and Administrator/Licensee have agreed to the following:

The department is requesting the following to be submitted by the Licensee by 6/22/23:

1. Updated LIC 500 to reflect Administrator’s hours on duty and all other staff schedules and hours

3. Administrator will conduct monthly audit of medication logs to verify accuracy of physician’s orders