Facility Evaluation Report

Licensing Program Analyst (LPA) Christina Valerio arrived to the facility unannounced to conduct a case management visit. LPA met with facility staff, and explained the purpose of the visit. LPA called Administrator Geoffrey to inform of visit. Administrator created the POC over the phone and designated staff to sign the documents.

LPA received a Facility Action Report dated 12/14/2022. According to records, the facility was not within compliance of Title 17 regulations for Medications and Training Plans. During the visit the following was cited:

The MAR incorrectly states the client is taking Perphenazine 8mg. The prescription label and prescription from the pharmacy both state the client is taking Perphenazine 16mg.

Acetaminophen 500mg with expiration date of 12/2023 was not logged on the Centrally Stored Medication Log.

The Peer Home #2 Program Design identifies monthly staff training. There was no documentation of monthly staff meetings present during the review.

LPA reviewed the centrally stored log, medication administrator records, and training plans. LPA found that a training was completed with 1 staff on 12/22/22 for the following topics (Facility Program Design, Individual Program Plan, Client's Rights & Responsibilities, Personal Rights, Medication Assistance, Health & Emergency Procedures, Special Incident Reporting, Client Abuse Identification Reporting). Medication records show that the facility fixed the errors found on 12/14/2022.

Based on records review and observations, deficiencies are being cited today on LIC 809 - D. Appeal rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held with facility staff, and a copy of the report was provided.