VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Virginia Veterans Care Center
4550 Shenandoah Ave.
Roanoke, VA 24017
(540) 982-2860

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Aug. 29, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

The LIs and facility management had a discussion regarding durable Do Not Resuscitate forms.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8/29/2022, 8:35 am to 2:45 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 13 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 6 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Susan Mallory, Licensing Inspector at (540) 309-3043 or by email at susan.mallory@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on record review, the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility?s own policies and procedures. EVIDENCE: 1. The record for resident 2 contained two annual TB Risk Assessment forms dated 1/1/2022 and 2/17/2021 in which resident 2 was assessed for TB symptoms and risk factors for developing TB. According to the screener?s signature on both forms, the two TB assessments were completed by a registered medication aide (RMA). 2. The Virginia Department of Health Professions Board of Nursing regulations governing the registration of medication aides, effective 2/6/2020, indicate that a Registered Medication Aide shall not perform acts beyond those authorized by the Code of Virginia for practice as a medication aide, which include making an assessment of a client.
Plan of Correction:	1. The TB Assessment for Resident 2 has been completed with the required signature of a Licensed Nurse. 2. Education has been completed with all licensed personnel that TB Assessments must be signed by a Licensed Nurse and cannot be signed by a registered medication aide. 3. An audit has been conducted to verify that all TB assessments have been signed correctly. 4. Audits will be done by the Unit Manager/Designee 3 x a week for 4 weeks and then 2 times a week for 4 weeks then weekly for 4 weeks and prn to verify that TB Assessments have been signed by a Licensed Nurse. Audit reports will be submitted to the DON/Designee as completed with any corrections needed. 5. Audit reports will be discussed at quarterly QAPI meetings until the issue is resolved.
Standard #:	22VAC40-73-120-A
Description:	Based on document review and interview, the facility failed to have complete new staff orientation for new staff. EVIDENCE: 1. New staff orientation 1 and 2 was lacking some required sections: the purpose of the facility; the services provided; the daily routines; specific duties and responsibilities of their positions; required compliance with the regulations for assisted living facilities as it relates to their duties and responsibilities; procedures for reporting and documenting incidents as required in 22VAC40-73-70; and for direct care staff; the needs; preferences; and routines of the residents for whom they will provide care.
Plan of Correction:	1. New staff orientation 1 and 2 was corrected and completed to show: the purpose of the facility; the services provided; the daily routines; specific duties and responsibilities of their positions; required compliance with the regulations for assisted living facilities as it relates to their duties and responsibilities; procedures for reporting and documenting incidents as required in 22VAC4073-70; and for direct care staff; the needs; preferences; and routines of the residents for whom they will provide care. 2. All new staff will be audited and any corrections/completions will be done to reflect the above issues. 3. Any new hires for the DOM will have the complete education/orientation as set forth by the Code of Virginia for Assisted Living Facilities.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review, the facility failed to ensure that TB screenings for staff were done within time frames. EVIDENCE: 1. The TB screening forms for staff 1 and 3 lacked dates to show when the screenings were done.
Plan of Correction:	1. The TB screenings for staff 1 and 3 have been completed as required. 2. The TB screens for all ALF staff have been audited for completeness and timeliness. 3. The Director of Infection Control has established that all staff will have their TB Assessment completed on the Birth Month and will verify that all have been completed each month.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to update individualized service plans (ISP). EVIDENCE: 1. Oxygen for resident 1 was discontinued, but it is still on the SIP dated 6/1/2022. 2. Resident 1 has allergies to latex, codeine, venflaxine [sic], PCN, quinapril, Effexor EW, terazosin, nifedipine, trazadone, ibuprofen, avelox, Cipro, and PPD serum. The ISP does not show what services are given to keep to make sure the resident does not get these medications.
Plan of Correction:	1. The ISP for Resident 1 has been revised to show that Oxygen has been discontinued. 2. The ISP for Resident 1 has been revised to show that Latex gloves will not be used in the care of the resident. Also any new medications will be compared to her allergy list and if there issues the PCP will be contacted prior to administration. 3. The Unit Manager/Designee will audit all ISP?s to verify that all discontinued items are reflected on the ISP. 4. The Unit Manager/Designee will audit new orders 3 x week for 4 weeks then 2 x week for 4 weeks then weekly for 4 weeks and prn to verify that any new orders are properly reflected on the ISP. Audits will be submitted to the DON/Designee as completed along with any changes. 5. Audit reports will be discussed at quarterly QAPI meetings until the issue is resolved.
Standard #:	22VAC40-73-990-C
Description:	Based on document review and interview, the facility failed to do complete six month practices of the plan for resident emergencies. EVIDENCE: 1. The most recent practice exercise of resident emergencies was on 10/6/2021. This was noted on 8/29/2022. 2. The practice exercise done on 10/6/2021 covered the missing resident situation, and lacked what to do in the event of a physical emergency or a mental health breakdown. This was confirmed in an interview with staff 7.
Plan of Correction:	1. A practice exercise for a physical emergency and for a mental health breakdown will be completed with staff. 2. Practice exercises will be conducted with staff every 6 months. 3. Unit Manager/Designee will verify that practice exercises are being completed with staff. The Unit Manager/Designee will submit a statement to the DON/Designee every 6 months with a list of completed exercises. 4. The issue will be discussed at the quarterly QAPI meeting until resolved.