VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brighter Living Assisted Living and Memory Care
5301 Plaza Drive
Hopewell, VA 23860
(804) 458-5830

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: April 30, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Technical Assistance:

Technical assistance offered to facility administrator to clarify issues which led to violations of regulations during this inspection. The Licensing Inspector reviewed the following standards with provider: 22VAC 40-73-210-B; 310-A; 325-A; 450-C and 970-A

Comments:

Two VDSS inspectors were on site on 04/30/2019 and 05/01/2019 to conduct a monitoring inspection and to follow -up on the Licensee's request to modify the current license. Based on the census offered, residents, staff and other facility records were reviewed for compliance. Interviews were conducted and observation of a noon time medication administration pass and meal times were also conducted. Facility staff did not submit documentation for the inspectors review that is required in order to modify the current license. There were no obvious physical plant concerns noted. The noncompliance revealed during this inspection is contained within this report. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov if you have any questions

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on the review of facility records and interviews conducted with the facility administrator the facility failed to ensure that all direct care staff shall attend at least 18 hours of training annually. EVIDENCE: Staff #2- Documented date of hire 05/172017 Upon request the facility did not submit for the inspectors review documented evidence that staff #2 obtained the required 18 hours of annual training. Facility records note that staff #2 only obtained nine (9) hours and twenty minutes of annual training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-310-A
Description:	Based on the review of facility records and interviews conducted with the facility administrator the facility failed to ensure that no resident was admitted or retained who requires a level of care or service or type of service for which the facility is not licensed. Evidence: Resident # 4 Records on file at the facility for the resident that were submitted for the inspectors review noted (1)-A 12/28/2018 Assessment of Serious Cognitive Impairment identified the resident as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia and that the resident is unable to recognize danger or protect his own safety and welfare. Additionally the resident was assessed as confused, poor judgement, poor concentration and had poor insight. (2)-The resident's 03/29/2019 UAI signed by the facility administrator on 04/08/2019 notes the resident to be disoriented in all spheres some of the time. (3)- The facility's Disclosure Statement updated 02/2018, that was submitted for the inspectors review on 04/30/2018 notes "No resident shall admitted for whom the facility cannot provide or secure appropriate care, or who requires a level of service for which the facility is not licensed and prospective residents may not have more than mild memory impairment and may not wander to be admitted on the assisted living side." During interviews, the administrator stated that at the request of the resident's POA the resident was discharged from an assisted living facility that is licensed as a safe and secure unit and admitted to this licensed facility that does not have a safe and secure unit. The facility did not submit for the inspectors review documented evidence that the resident had been reassessed and a determination made that a change in condition occurred resulting in the resident no longer having a serious cognitive impairment and that the resident can protect his own safety and and welfare.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-325-A
Description:	Based on the review of facility records and interviews conducted on 04/30/2019 and 05/01/2019 with the facility's Administrator and other facility staff, the facility failed to complete a written fall risk assessment by the time the comprehensive ISP was completed for residents who meet the criteria for assisted living care. Evidence: Resident #1- Documented date of admission 11/05/2018. Upon request the facility did not submit for the inspectors review documented evidence that a fall risk assessment had been conducted for the resident prior to the required thirty day comprehensive ISP. An Initial assessment/ Fall Risk Worksheet that was in the resident's record and reviewed and discussed with the facility administrator was observed to be blank.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-C
Description:	Based on the review of facility records and interviews conducted with the Administrator and other facility staff on 04/30/2019 and 05/01/2019, the facility failed to ensure that the comprehensive individualized service plan included the expected outcome and time frame for expected outcome. Resident #1- Documented date of admission- 11/05/2018 The resident's 04/05/2019 ISP that was submitted upon request for the inspectors' review did not indicated an expected outcome date or time frame for expected outcome.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-970-A
Description:	Based on the review of facility records and interview conducted with the facility Administrator the facility failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: Facility documentation that was submitted for the inspectors review noted the following fire drills were conducted during the 7-3 shifts: 02/18/2019 at 2:53p.m(7-3 shift); 02/26/2019 at 9:30a.m (7-3 shift) and 03/19/2019 at 8:30a.m (7-3 shift).
Plan of Correction:	Not available online. Contact Inspector for more information.