VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bellaire at Stone Port
1684 Port Hills Drive
Harrisonburg, VA 22801
(540) 246-0888

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: Sept. 24, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL

Technical Assistance:

The licensing inspector met with the administrator and discussed the following: 1) When using the direct care aide (DCA) curriculum, you must use the entire curriculum and not pick and choose what you wish to cover - including the activities, tests, etc. 2) The administrator must submit a letter to this inspector stating he plans to use the DCA curriculum in its entirety to provide a minimum of 40-hours of training. He must also submit a copy of his current nursing license along with this letter. 3) Discussed refining the process for registering and issuing certificates for first aid and cardiopulmonary resuscitation classes to ensure accuracy of attendance and completion.

Comments:

The licensing inspector conducted an unannounced complaint inspection in response to a complaint that was received in the licensing office on 9/9/19. Interviews were conducted with staff relating to allegations of direct care and first aid training not being conducted as required. The information gathered during the inspection supports the allegations, so the complaint is determined to be valid. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendar days of receipt. If you have any questions contact your licensing inspector at (540) 430-9258.

Violations:

Standard #:	22VAC40-73-200-C-7
Complaint related:	Yes
Description:	Based upon documentation and an interview, the facility failed to ensure six of the six new staff hired completed the 40-hour direct care class (DCA) and to ensure a registered nurse (RN) or licensed practical nurse (LPN) conducted the training. Evidence: 1) Staff A, B, C, D, E and F had a DCA training certificate on file indicating completion of the 40-hour DCA class approved from the Virginia Department of Social Services. 2) On 9/24/19, the licensing inspector (LI) interviewed staff who stated this training was not a class and that they were mostly trained by their coworkers "while working the floor." Staff also did state the administrator observed them complete the tasks of activities of daily living. 3) On 9/24/19, the LI interviewed the administrator who was the RN responsible for the training. He stated, "I used portions of the DCA curriculum but purchased a certified nurses'aide (CNA) program book and DVD that we used as it was more skills based. No tests were administered except with observation to ensure skills. They sit at the nurses station and watch the videos and then senior staff observe them and complete a checklist." The administrator stated he would observe some portions of the performance of skills with the activities of daily living. 3) The DCA curriculum in the orientation section states on page 7, "This training must be provided by a registered nurse or licensed practical nurse. Strictly follow the methods of instruction provided in the curriculum including class discussions, training exercises, games, etc".
Plan of Correction:	1) Staff A, B, C, D, E and F will complete the 40-hour classroom class for the DCA curriculum. Training will be provided by approved RN or LPN instructor provided by the contract pharmacy. 2) New staff will be required to have a DCA, personal care aide (PCA) or certified nurses' aide (CNA) certificate on file prior to starting employment with the facility going forward. 3) Director of health and wellness (DHW) and business office manager (BOM) will ensure compliance with this standard.
Standard #:	22VAC40-73-260-A
Complaint related:	Yes
Description:	Based upon documentation and an interview, the facility failed to ensure 10 of the 47 staff reviewed completed first aid (FA) training within 60 days of hire. Evidence: 1) Staff A (hired 5/7/19), B (hired 5/21/19), C (hired 6/4/19), E (hired 3/19/19), G (hired 6/11/19), H (hired 7/2/19), J (hired 3/19/19), K (hired 4/9/19), L (hired 5/7/19) and M (hired 6/25/19).had no documentation of completion of FA. 2) On 9/24/19, the LI interviewed the administrator and business office manager and both stated these staff had not completed first aid training. 2) Staff A, E, G and L had FA and CPR certificates on file; however, according to interviews, the staff did not attend the class and the certificates were given out in error due to a breakdown in communication.
Plan of Correction:	1) Staff A, B, C, E, G, H, I, K, L and M have been scheduled for FA and CPR classes on 11/19/19. Training to be provided by an approved instructor provided by the facility contract pharmacy. Two classes will be held on 11/19/19 to accommodate up to twenty students. 2) The facility contract pharmacy will schedule FA and CPR classes on a regular schedule at Bellaire offering classes bi-monthly to ensure compliance. The DHW and BOM will ensure compliance with this standard.