Facility Evaluation Report

On 6-20-23 at 9:00am, a meeting was held with licensee to discuss a Technical Support Program Engagement Summary (TSP) generated on 05/25/2023. This meeting was held virtually via Teams Meeting. Present at this meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Maja Jensen, LPA Jennifer Fain, and Ombudsman Kathryn Thomas. At the beginning of the meeting, Licensee confirmed receipt of TSP material from virtual visits on 2/7/23, 2/23/23 and 3/2/23 as well as the on site visit from 2/23/23.

LPM and LPA discussed the following topics previously addressed at the TSP Engagement:

· Licensee generated system to track specific files requiring updates

· Use of CARE tools to aid in maintaining compliance

· Communication with LPA to preemptively address discovered issues and resolutions

· Assessment procedures to ensure staff are able to meet needs of clients

· Reporting requirements such regulatory requirements and what constitutes an incident report

· Medication Management including destruction of Medication and PRN’s