Evans House

Based on documentation review, record review and interview, the administrator did not ensure a personnel member's skills and knowledge was verified and documented before the personnel member provided physical health services, habilitation services, or behavioral care for two of five personnel sampled. Findings include: 1. A review of facility documentation revealed a "Schedule Builder" which verified E1, E2, E3, E4, and E5 were scheduled to provide services during the month of July 2025. 2. A review of E1's, E2's, E3's, E4's, and E5's personnel record revealed documentation of E1's, E2's, E3's, E4's, and E5's skills and knowledge was not available for review. 3. In an interview, E6 acknowledged E1's, E2's, E3's, E4's, and E5's skills and knowledge was not verified and documented before E1, E2, E3, E4, and E5 provided physical health services, habilitation services, or behavioral care.

Based on documentation review and interview, the administrator did not ensure policies and procedures for medication administration were reviewed and approved by a pharmacist. Findings include: 1. A review of the facility’s policies and procedures revealed a policy titled “Medication Administration.” However, the policy did not include documentation of having been reviewed and approved by a pharmacist. 2. In an interview, E6 acknowledged the policies and procedures for medication administration were not reviewed and approved by a pharmacist.