Facility Evaluation Report

Licensing Program Analyst (LPA) Steve conducted a case management visit to assess resident R1 and R2 for total care exception request. LPA met with Administrator Debbie Cota (ADM) and stated the purpose of today's visit.

During today's visit, LPA met resident R1. Resident R1 is dependent on staff to care and supervise R1's activity's of daily living (ADLs). LPA introduced self to R1. LPA asked R1's name but R1 did not reply. ADM asked if R1 wants to eat something and R1 replied yes. ADM gave a spoon of pudding to R1 to eat and asked if R1 likes it. R1 replied yes. ADM asked R1 if R1 needs more pudding and R1 replied yes. ADM gave more spoons of pudding to R1 and asked R1 if R1 likes it. R1 replied yes. ADM asked R1 if R1 is happy and R1 answered yes. ADM asked R1 if R1 needs some water and R1 shook his head no. LPA asked R1 if R1 is happy. R1 smiled and replied yes.

Based on the observation, R1 is able to communicate his/her needs/likes by verbal communication and shaking head. Based on the observation, total care exception is not needed at the time for R1.

The facility staff shall continue to document R1’s condition and care provided should be kept in R1's files. Any changes in R1’s condition should be reported immediately to R1's primary care physician, responsible party and licensing agency. Facility staff will monitor R1's health care needs and collaborate with R1's primary physician regarding care. Facility staff shall ensure R1's Appraisal Needs and Services Plan is updated annually or as needed if the resident experiences significant physical or mental changes. Facility shall provide ongoing annual staff training specific to the needs of resident and shall be documented in facility records.