Facility Evaluation Report

On 3/9//2023 Licensing Program Analyst (LPA), Tobola conducted a Case Management for the purpose of a Quarterly Non-Compliance visit and was greeted by Administrator, Dae Harris.

LPA toured the facility and conducted a spot medication count of both narcotic and general prescription medication for 6 clients with med-tech staff. LPA and med-tech staff manually counted medication based on start date and record and found all times to be in order. LPA informed that lead DSP staff are in the process or currently double trained on the med-tech position for backup medication administration and recording in case of call-outs or emergencies.

LPA also reviewed previously cited deficiencies from complaint investigation conducted on 2/16/2023 with Administrator and discuss the plan of corrections to be submitted to CCLD. Administrator has reviewed all LIC602's determining clients who may not be out of the facility unassisted. Administrator has also reviewed reporting requirements with all lead staff with plans to review all discharge paperwork and report incidents to Administrator within a 24 hour period for more efficient reporting to CCLD. Administrator to submit written plan of correction statements to CCLD by 3/10/2023.

Lastly, LPA conducted a follow up on several incident reports involving physical altercation between C1 & C2 resulting in C1 being transferred out of the facility due to emergency relocation for level of care. In addition, LPA found that client C3 had been transferred to a behavioral health facility. LPA interviewed C2 and found them to be calm and "feeling better" after the altercation. Administrator will be submitting Incident Report after C2 had not returned after a planned outing. C2 returned the same day of the incident with no injuries or changes of behavior.

No deficiencies cited during today's visit.