Facility Evaluation Report

Licensing Program Analyst (LPA) Melody Brown arrived at the facility 03/30/2022 at 12:40 PM unannounced in order to complete the facility's Annual Inspection. LPA Brown met with House Manager Lanny Latta 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 Brown went over COVID-19 best practices for infection control and prevention with House Manager Lanny Latta and House Manager Latta reported that Mitigation Plan was submitted 07/12/2021. LPA Brown observed the facility having Covid-19 signages throughout the facility for proper hand washing procedure and social distancing. However, LPA Brown observed no central entry point and routine symptom screening has been designated for universal entry screening. LPA Brown requested House Manager Latta to set-up Central Entry Point and Routine Symptom Screening and LPA Brown discussed its importance to House Manager Latta. LPA Brown will be issuing a deficiency as this practice has a health and safety impact that includes but is not limited to personal rights, health related services and personnel requirements. Central Entry Point and Universal Screening has been set-up during the visit.

LPA Brown toured the facility's and observed that resident bathrooms have paper towels and hand soap. LPA Brown requested to inspect the facility's Personal Protective Equipment (PPE) supply. LPA Brown observed the facility to have a sufficient supply of sanitizer, gloves, masks but no face shields/goggles and isolation gowns. LPA Brown will be issuing a Technical Assistance Advisory Note instead of a deficiency due it being difficult to access face shields and isolation gowns at numerous points during the COVID-19 pandemic. LPA Brown advised the facility to look online for items missing from their PPE supply kit, as CCL may not have these items to supply them with.

LPA Brown went over the various recommended training for facility staff with House Manager Latta in relation to COVID-19 and House Manager Latta reported that all staff were trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing of PPE.