Office review·June 15, 2023

On 6-15-23 at 11:00am, regional office conducted an informal meeting with facility to discuss recent citations issued and additional concerns. This meeting was held virtually via Teams Meeting. Present at the meeting were Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Michael Bilger, Licensing Program Analyst Jennifer Fain, and Administrator Beatrice Clark. Topics in this meeting included but not limited to the following: (1) Incidental Medical care (2) Maintenance and Operation, (3) Exceptions for Restricted and Prohibited health conditions regarding presence of wounds and catheter care, (4) Care and Supervision regarding wounds and (5) Staffing levels LPAs Bilger and Fain, and LPM King discussed with administrator citations issued between 11-16-22 and 4-18-23 and the associated plans of correction going forward. Administrator stated medication are audited by her to ensure accuracy and a plan going forward will be implemented to ensure medication listed on log sheets match physicians’ orders. Administrator further stated she is currently working more than 40 hours per week at facility and two staff are on duty at all times. In regards to catheter care, Administrator stated she is now aware of the need for exceptions for catheter care and other restricted and prohibited conditions The following are the results from complaint allegations previously issued and Administrator/Licensee have agreed to the following: The department is requesting the following to be submitted by the Licensee by 6/22/23: 1. Updated LIC 500 to reflect Administrator’s hours on duty and all other staff schedules and hours 2. Updated LIC 308 as changes occur 3. Administrator will conduct monthly audit of medication logs to verify accuracy of physician’s orders {cont. on 809C} 4. Administrator will seek services of a home health agency for training purposes regarding wound care prevention and other potential areas regarding care and supervision as needed. 5. Administrator will maintain and update needs and service plans for residents going forward for any changes in conditions including conditions which may warrant an exception for various types of care interventions. The department is requiring Administrator be on duty at facility for no less than 40 hours per week. Department shall conduct quarterly visits to ensure compliance with above and all other Title 22 requirements. Quarterly visits shall consist of, but not be limited to: (1) Review of client and staffing files, (2) Review of medication administration records and audit sheets, (3) Physical Plant inspections, (4) Staffing schedules, (5) Wound prevention plan LPM and LPAs notified Administrator that future non-compliance regarding the above and other regulatory components will result in additional citations, civil penalties, and a non-compliance conference to discuss further potential administrative action. No citations issued today. An exit interview was conducted with Beatrice Clark and a copy of the report was emailed to Beatrice with request for return with signature.