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. LPA met with administrators Blythe McClanahan and Frank Pesqueira and advised them 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 both administrators who are 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 the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, social distancing, and 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 a storage are in the garage 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 and administrators discussed the need for additional PPE on hand specifically gowns and N95 masks. LPA will be issuing a Technical Assistance Advisory Note during today's inspection for Administrators to procure additional PPE to be kept on hand at the facility.LPA and Administrators discussed creating a box, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put inside and outside of an isolation room. LPA inquired as to if staff have been fit tested for N95 masks, and Administrators 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, all staff and clients have been vaccinated and are practicing other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

LPA and Administrators discussed 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 and LIC9102 TA Advisory Notes were discussed and provided to the Administrators.