Licensing and administrationType B
- Official classification
- Type B
- Official code
- 1569.618(c)(3)
- Regulation authority
- HSC
What the official deficiency says
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in three out of three staff files which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/13/2024 Plan of Correction Administrator will email the valid CPR/First Aid for three out of three staff.
Fire safety and emergency preparednessType B
- Official classification
- Type B
- Official code
- 1569.695(c)
- Regulation authority
- HSC
What the official deficiency says
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirement is not met as evidenced by: Deficient Practice Statement Based on record review, the licensee did not comply with the section cited above in one out of one emergency drill folder which poses/posed a potential health, safety or personal rights risk to persons in care.
Official plan of correction
POC Due Date: 12/13/2024 Plan of Correction Administrator stated they believed the emergency drill was yearly and will conduct and document quarterly moving forward. Administrator will email LPA proof of an emergency drill conducted by POC date.