Facility Evaluation Report

On 4/28/2021 LPA Tobola conducted a Case Management for the purpose of a Quarterly Non-Compliance visit and was greeted by Administrator, Eleina Ridolfi (ER). LPA conducted a tour of the facility and found it to be clean and at a comfortable temperature. During LPA's prior quarterly visit the window in client bedroom 3 was found to be in disrepair and coming out of frame. LPA and Administrator reviewed the repairs of the window and is found to be in order. LPA did not observe any other physical plant or plumbing items in disrepair on this day at the time of visit.

LPA also conducted a spot medication count with lead med-tech staff Na'Dira Serquina (NS) for 3 of 3 clients and found all medications and administration count to be in order. All medications are recorded on an electronic Medication Administration Record. Any missed or refused medications are also recorded. No medication errors were observed from the spot medication check. LPA was informed that there currently 4 med-techs on staff. LPA requested for med-techs to review electronic Medication Administration Record procedures and how to access medication that has already been administered to clients. Administrator stated that medication room audits are now conducted per shift change as well as random audits by outside consulting company.

LPA was informed that TSP services have been engaged at this time to address deficiencies noted in Non-Compliance meeting. Exit interview was conducted with Administrator whose signature on this document confirms receipt.

No deficiencies cited during today's visit.