Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
15-Mar-2022
Subject
["Policies (Includes issues such as not following, insufficient information or policy missing)"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A Licensee must do all of the following: operate the community care facility in a manner that will promote the health, safety and dignity of persons in care.
Observation: Through the investigation process, Licensing determined that the facility had not appropriately documented COVID-19 screening of visitors.
Corrective action: Ensure that the community care facility is operated in a manner that promotes the health, safety and dignity of persons in care. Specifically, that COVID-19 screening was documented. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 5 and 12, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that by May 20, 2022 and the facility would visibly display instructions for visitors to complete the COVID-19 screening logs and logs would be audited weekly to ensure completion. This corrective action plan had been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up inspection required. On July 20 and 21, 2022, Licensing received a memo, dated June 16, 2022, addressed to visitors that reviewed the screening process and a weekly screening audit which included education provided to visitors about documentation.
To be corrected by: 17-Aug-2022
A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Observation: Through the investigation process, Licensing determined that a person in care's care plan had not been revised with a change in circumstance.
Corrective action: Ensure that each care plan s reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 5 and 12, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that by June 1, 2022, all regular Licensed Practical Nurses (LPNs) on the Dayton unit would review the care plan policy and sign off their understanding, leadership would complete a total of ten care plan audits by June 30, 2022, to ensure care plans were updated accordingly and the person in care had been discharged from care on April 1, 2022. This corrective action plan had been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up inspection required. On July 20 and 21, 2022, Licensing received the Care Plan Initial and Review policy which had been signed by LPNs on June 30, 2022 and a care plan audit for 20 persons in care was received which indicated which care plans had been reviewed.
To be corrected by: 17-Aug-2022
A Licensee must do all of the following: operate the community care facility in a manner that will promote the health, safety and dignity of persons in care.
Observation: Through the investigation process, Licensing determined that the facility had not appropriately documented COVID-19 screening of visitors.
Corrective action: Ensure that the community care facility is operated in a manner that promotes the health, safety and dignity of persons in care. Specifically, that COVID-19 screening was documented. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 5 and 12, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that by May 20, 2022 and the facility would visibly display instructions for visitors to complete the COVID-19 screening logs and logs would be audited weekly to ensure completion. This corrective action plan had been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up inspection required. On July 20 and 21, 2022, Licensing received a memo, dated June 16, 2022, addressed to visitors that reviewed the screening process and a weekly screening audit which included education provided to visitors about documentation.
To be corrected by: 17-Aug-2022
A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Observation: Through the investigation process, Licensing determined that a person in care's care plan had not been revised with a change in circumstance.
Corrective action: Ensure that each care plan s reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On May 5 and 12, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that by June 1, 2022, all regular Licensed Practical Nurses (LPNs) on the Dayton unit would review the care plan policy and sign off their understanding, leadership would complete a total of ten care plan audits by June 30, 2022, to ensure care plans were updated accordingly and the person in care had been discharged from care on April 1, 2022. This corrective action plan had been reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up inspection required. On July 20 and 21, 2022, Licensing received the Care Plan Initial and Review policy which had been signed by LPNs on June 30, 2022 and a care plan audit for 20 persons in care was received which indicated which care plans had been reviewed.
To be corrected by: 17-Aug-2022