Facility Evaluation Report

Licensing Program Analyst (LPA) Tricia Danielson arrived unannounced to the facility to conduct an annual inspection with emphasis on infection control. LPA met Mary Grace Winters, Program Manager with and explained the purpose of today’s visit. The facility has a Mitigation Plan Report on file as well as an Infection Control Plan as required. Program participants were not present during today's visit however, there are twenty-five (25) participants who are enrolled for services. Program participants are in house Mondays, Wednesdays, and Fridays.

During the inspection, LPA observed appropriate COVID-19 postings at the facility front entrance and throughout the facility itself. The facility has a COVID-19 symptom and temperature screening process in place which was in accordance with the Department's guidelines. LPA observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). LPA observed facility staff wearing appropriate face coverings. As documented in the facility's Mitigation Plan Report (Report), the facility has a designated infection control lead person/infection preventionist who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring staff are trained in the facility's infection control procedures, and ensuring infection control measures are implemented. Also detailed in the Report, the facility has a plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for program participants and staff with COVID-19 positive results and/or exposures. Additionally, the Report describes the facility's plan to monitor program participants regularly for any changes in condition and to subsequently notify the program participant's physician, emergency personnel, and responsible party in the event the program participant presents with any COVID-19 symptoms.

No deficiencies were cited during today's visit. An exit interview was conducted, and a copy of this report was provided along.