VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Linden House
1250 Branchlands Drive
Charlottesville, VA 22901
(434) 973-0311

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: July 28, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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-40-73-40.A; 450.C; 460.B and 680.D

Comments:

This complaint investigation was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. The complaint investigation was initiated on 07/28/2020 and concluded on 11/30/2020. The facility Administrator was contacted by telephone to initiate the inspection. The facility Administrator reported that the current census was 61. The inspector emailed the facility Administrator a list of items required to complete the investigation. The information gathered during the complaint investigation and interviews conducted determined non- compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. It has been determined that the complaint is valid. 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 angela.r.reaves@dss.virginia.gov. if further assistance is needed.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based on the review of facility records and interview conducted the facility 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: Resident #1-Documented Date of Admission 02/20/2020 The facility?s Medication Management Plan that was submitted for the inspector?s review via a 11/16/2020 email notes in part ? Medications sent to the facility following a hospitalization or skilled nursing stay will be verified by the Nurse with the resident?s primary care physician and then submitted to the pharmacy for order entry and medication delivery to the community." The complainant reported that resident #1 was discharged back to the facility from a local hospital on 05/17/2020 and that medications prescribed for him were not administered until six days later on 05/22/2020. The facility Administrator stated that the facility?s nurse practitioner alerted the facility about the medication not being on the resident?s Medication Administration Record (MAR) thus the facility determining that the identified medications had not been administered to resident #1. During interviews the facility Administrator also stated that facility staff #1 was the nurse on duty that was responsible for verifying the new medication orders but did not follow through per facility policy.
Plan of Correction:	FACILITY RESPONSE- "1) Wellness Directors, LPN supervisors, and RMA supervisors are re-educated on the medication management plan regarding procedures following re-admission from the hospital. 2) Wellness Director or designee reviews the electronic record and 24 hour report daily to identify re-admissions to facility and then audits to ensure resident?s primary care physician has been notified for order verification following readmission, and any new orders or discontinued orders have been communicated to the pharmacy within 24 hours of readmission. Additionally, facility readmissions and new admissions will be reviewed in daily clinical meeting Monday-Friday to ensure that new or discontinued orders are reflected on the eMAR, medications have been received from pharmacy, and physician orders are followed. 3) The Wellness Director and/or Executive Director will ensure compliance of these preventative measures and compliance."
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on the review of facility records and interview conducted the facility failed to include a written description of what services will be provided to address identified needs. EVIDENCE: Resident #1-Documented Date of Admission 02/20/2020 The facility?s undated Initial Admission Fall Assessment that was submitted for the inspector?s review noted in part ?Resident is disoriented and confused at times or always; Inability to understand and follow directions; Resident has cognitive loss and demonstrates exit-seeking behavior; the resident is at risk for elopement and requires safety interventions and that the resident required safety checks around the clock. The resident?s Individualized Service Plan (ISP) dated 03/11/2020 under the heading ?Other communication, behavioral or cognitive? needs in part notes that due to the resident?s Alzheimer?s Disease and anxious or frustrated behavior that facility staff are to contact the resident?s son (identified). The resident?s ISP does not however identify what specifics of the son?s intervention have been identified for facility staff to implement, does not document a plan for facility staff to monitor the resident for safety checks around the clock and does not identify an expected outcome and time frame for expected outcome.
Plan of Correction:	THE FACILITY'S RESPONSE -"1) Wellness Director, Memory Care Manager, and Assistant Administrator have been re-educated on identification and inclusion of all resident?s needs using admission assessment tools such as UAI, resident risk ratings (i.e. fall risk rating, elopement risk rating) and wellness evaluation (need for safety checks, behaviors and management, assist with hearing devices, etc.) for inclusion on the resident?s ISP. Re-education also includes identification and inclusion of specific behavior management interventions for residents with behaviors, the expected outcomes of the interventions, and next steps for staff to utilize if identified interventions are not effective in a specified timeframe. 2) Wellness Director or designee will update resident?s ISP during daily clinical meeting following new fall, new exit seeking behavior, need and plan for safety checks, and new behaviors with appropriate interventions for target behavior, expected outcomes, and steps to take if ineffective in a specified timeframe. The executive director or assistant administrator will perform a monthly audit of 4 residents who had one or more of the following: a new fall, new exit seeking behavior, new need for safety checks or have new behaviors to ensure all needs have been included on their ISP with interventions to assist resident and to ensure behavior management interventions include expected outcomes and the next steps for staff to utilize if identified interventions are not effective in a specified time frame. 3) Wellness Director and Executive Director will ensure compliance of these preventative measures and compliance will be achieved."
Standard #:	22VAC40-73-460-B
Complaint related:	No
Description:	Based on the review of facility records and interview conducted the facility failed to ensure prompt response by staff to a resident?s needs as reasonable to the circumstances. EVIDENCE: Resident #1- Documented date of admission 02/20/2020 The complainant reported that a skin tear to resident #1 that was reported and assessed by the facility staff on the day of admission had not been changed for approximately 10 days. The date of the bandage application was questioned approximately one week later when it was noticed during a visit. The facility failed to change the bandage until this was reported a second time, after an additional 3 days had transpired. 03/06/2020: Linden House Assisted Living Observations document that was submitted for the inspector?s review in part notes ?DCS reported that family found dressing on resident?s right distal forearm with (identified staff?s) initials and 02/26 date.? The document also notes ?when the nurse pulled up the sleeve the dressing was dirty and covered entirely with dark colored balls, 2 open areas noted with approx. 25 cent area of dark brown old blood, with small amount of serosanguinous drainage on the nonstick telfa dressing. Family witness the dressing change and stated resident only had one skin tear when he was admitted?; and questioned why is there were two areas now. Facility documentation revealed that the facility was aware of the skin tear upon admission and that on 02/26/2020 six days after admission the bandage had not been changed. The facility did not promptly provide treatment to the resident.
Plan of Correction:	FACILITY'S RESPONSE- "1) Wellness staff are re-educated on staff responsibilities regarding facility policy and procedures for identification and follow up of skin alterations to include obtaining treatment orders and following physician orders for dressing changes. 2) Wellness director or designee reviews the electronic record and 24-hour report daily to identify residents with new skin tears or other skin alterations. The record for each resident is audited to ensure treatment orders have been obtained and added to the eMAR for follow up. Residents with skin tears and skin alterations are added to the 24-hour report and maintained there for ongoing nurse assessment and/or follow up until the area is healed. 3) The Wellness Director and/or Executive Director will ensure compliance of these preventative measures and compliance achieved"
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on the review of facility records and interview conducted the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: Resident #1- Documented date of admission 02/20/2020 The complainant reported that it took ?5 days from his discharge on May 17 until 8 PM on May 22 for his first dose of Cinacalet? and ?6 days (May 23) to receive the first dose of K-PHOS? The investigation confirmed that resident #1 was discharged from the hospital and returned to the facility on 05/17/2020. Facility records submitted for the inspector?s review and during interviews the facility administrator confirmed that at the time the resident returned the facility was in possession of the prescriptions for the 1-30 mg tablet of the medication Cinacalcet to be administered two times a day and for 1-250 mg tablet of the medication K-PHOS to be administered daily for three days. Facility records that were submitted for the inspector?s review noted that resident #1 was not administered the medication K-PHOS until 05/22/2020; five days later and beginning 05/18-21/2020; was not administered nine dosages of the medication Cinacalcet.
Plan of Correction:	FACILITY'S RESPONSE- "1) Wellness Directors, LPN supervisors, and RMA supervisors have been re-educated on the medication management plan regarding procedures following re-admission from the hospital. 2) Wellness Director or designee reviews the electronic record and 24 hour report daily to identify re-admissions to facility and then audits to ensure resident?s primary care physician has been notified for order verification, and any new orders or discontinued orders have been communicated to the pharmacy within 24 hours of readmission. Additionally, facility readmissions and new admissions will be reviewed in daily clinical meeting Monday-Friday to ensure that new or discontinued orders are reflected on the eMAR, medications have been received from pharmacy and physician orders are followed. 3) The Wellness Director and Executive Director will ensure compliance of these preventative measures and compliance achieved."