Arbor Terrace Citrus Park received a rare deficiency-free survey in an inspection last month by the Florida Agency for Health Care Administration.
The inspection, conducted every two years by the agency that oversees health care facilities and assisted living communities in the state, features an extensive look at medical record; personnel files; COVID-19 policy; safety protocols; resident complaints; and more. A community must pass the inspection to maintain its license to operate.
The intensive investigation examines every aspect of a community’s operation. The state of Florida has stringent standards, and it’s unusual for a community to finish the inspection without a single deficiency, said Teresa Covelli, executive director of Arbor Terrace Citrus Park.
“It’s a full-blown audit of everything and anything in the community,” she said. “Each and every department is scrutinized to make sure the policies and procedures the state has in place are being followed, and then Arbor’s policies and procedures.”
Even if a community is compliant with state regulations, if the inspectors find that Arbor procedures are not being followed, that could lead to a lower rating.
According to Covelli, preparing for the process was a learning experience for the team. The community also received a three-month extension from ACHA this year because of the upheaval related to the COVID-19 pandemic.
“In that time, I said, ‘We need to be state-ready all the time, make sure paperwork is proficient.’ All the department heads, working together, were making sure as we were going along that we were doing everything the right way the first time, so that when the state walks in, we welcome them and we’re happy to see them. So I was ready for them,” Covelli said.
There also were no resident complaints for ACHA to review; resident complaints often will lead to a community receiving deficiencies on a survey.
Covelli credits the good team she has.
“My nursing team that’s in place right now is solid. They know what the expectations are,” she added. “We review what has to be done. We go through policy and procedure of ACHA, the law and the rules, and I think there’s a really good understanding with nursing, as well as the business office.”
