VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Humphrey's Retirement Home
3405 Chamberlayne Avenue
Richmond, VA 23227
(804) 329-1316

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Oct. 12, 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 X 22VAC40-73 RESIDENT CARE AND RELATED SERVICES X 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND X 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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:

Discharge statement completion

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: 10-12-2022, 8:39 a.m. ? 10:30 a.m. and 3:00 p.m. ? 3:30 p.m. 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: 24 Number of resident records reviewed: 6 Number of staff records reviewed: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: Tour, medication pass, record review 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 Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISP) were signed and dated by the licensee, administrator or designee and by the resident or his legal representative. Evidence: 1. Resident #5 admitted 12-08-2011. Resident #5?s current ISP on file was not signed and dated by the facility representative or the resident or resident?s legal representative. 2. Staff #1 acknowledged during interview that Resident #5?s ISP was not signed by either party.
Plan of Correction:	Administrator will make sure documents are signed by the appropriate individuals.
Standard #:	22VAC40-73-520-I
Description:	Based on record review, the facility failed to ensure the written schedule of activities documented the house of the activity. Evidence: The facility?s schedule of activities for August and September 2022 was missing the times for ?Table Games? Activity for dates 8-08-2022, 08-22-2022, and 9-19-2022.
Plan of Correction:	Administrator will make sure time of activities are included and write in any changes.
Standard #:	22VAC40-73-650-E
Description:	Based on record review and interview with staff, the facility failed to ensure the resident's record contained the physician's or other prescriber's signed written order or a dated notation of the physician's or other prescriber's oral order. Evidence: 1. Resident #8 was administered Latuda 20 mg on 10-12-2022 during the medication administration observation by licensing staff. 2. A review of Resident #8?s record confirmed there was no documentation of the physician?s order. 3. Staff #1 stated there was not a signed physician?s order on file for or Resident #8?s Latuda 20 mg at the time of inspection.
Plan of Correction:	Administrator will peruse POS to make sure all monthly signed.
Standard #:	22VAC40-73-750-B
Description:	Based on observation and interview with staff, the facility failed to ensure bedrooms contained an operable bed lamp or bedside light accessible to each resident. Evidence: 1. During a tour of the facility, room 7 and room 12 had four residents each, with no lamp for any of the eight residents. 2. Staff #1 confirmed the bed lamp or bedside lights were not in room 7 or room 12.
Plan of Correction:	Administrator will add to ISP clients need for lamps if they do not wish to have one in their rooms.
Standard #:	22VAC40-73-960-B
Description:	Based on observation and interview with staff, the facility failed to ensure the fire and emergency evacuation drawing showed primary and secondary escape routes, areas of refuge, assembly areas, and telephones. Evidence: 1. The fire and emergency drawing observed on the second floor did not contain primary and secondary escape routes, areas of refuge, assembly areas, and telephones. 2. Staff #1 observed during the tour and acknowledged that all required areas were not seen on the drawing. Photographic evidence was obtained.
Plan of Correction:	Administrator will go back and include the pertinent information that was missing.