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: Aug. 27, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced focused monitoring inspection was initiated on 08/27/2021 by the licensing inspector to follow up on the facility's Intensive Plan of Correction (IPOC) regarding the Licensee, Personal care services and general supervision and care and Administration of medications and related provisions. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 79. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, the facility?s medication administration records, staff training/in-service, Uniform Assessment Instrument (UAI), ISPs, and facility nurses notes to ensure that documentation was complete. The inspector conducted the on-site portion of the inspection on 10/07/2021. An exit interview was conducted with the Administrator on the date of inspection and on 10/11/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined repeat and new noncompliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. If you have any questions I can be reached at (804z0 840-0253 or angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
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: In response to the Licensee not providing oversight to the facility; the facility?s Intensive Plan of Correction (IPOC) response that was submitted for the inspector?s review notes in part ?Licensee shall 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.? Facility Medication Administration Records (MARs), physician orders and staff interviews conducted revealed: Beginning August 2021 to present in regards to resident medications being administered per physician?s orders; facility staff are documenting: not in cart, awaiting on delivery from pharmacy, New order not here, medications were not available?. Additionally; ? Facility staff documented on 09/09/2021 that while counting the narcotic oxycodone- the medication was noted on the MAR and no medication was in the med cart. ? PRN medications are being administered by registered medication aides (RMA) without required authorization/documentation ? Resident Individualized Care Plans (ISP) are not developed based on assessed needs ? Resident in the safe and secure environment allowed to sign her own ISP ? Resident incident reports are not being submitted as required. ? Fall risk ratings and analysis are not being conducted after each resident fall. The approved IPOC is not being followed.
Plan of Correction:	FACILITY'S RESPONSE: "The Facility Executive Director and/or designee will re-educate the Facility Wellness Director on the Medication Management Plan and coordinate support services with Remedi Pharmacy to re-educate all appropriate staff on the systems and processes and forms used to ensure compliance with the DSS Approved Medication Management plan and this standard, also all facility reported incidents will be reported by the Executive Director and/or designee in accordance with this standard and all applicable laws and regulations. The facility Wellness Director and/or designee will complete a comprehensive chart audit to ensure all lSP's address assessed needs of the individual resident, fall risk ratings and analysis are completed timely and in accordance with this standard, all PRN medications are administered appropriately, and that residents who reside in the secured environment will have their POA or other responsible party sign their Individualized service plan. The facility Wellness Director and/or designee will coordinate with Remedi Pharmacy representative to ensure all appropriate systems are in place and forms readily available to staff to ensure refills of medication are completed timely. After the initial audit the Wellness Director and/or designee will conduct sample audits once per month for 3 months, then once per quarter for 3 quarters to ensure continued compliance."
Standard #:	22VAC40-73-70-A
Description:	Based on the review of facility records and interview conducted the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: Resident #1 Documented date of admission 04/02/2019 The facility?s Linden House Assisted Living Facility Observations document charting for September 2021 that was submitted for the inspector?s review revealed that on 09/04/2021 the resident was sent out from the facility to a local hospital for emergency medication intervention due to injuries sustained while in care at the facility. The facility did not submit an incident report regarding this matter to the regional licensing office as required. During the 10/11/2021 telephone interview facility staff #1 stated that she could not locate an incident report regarding the 09/04/2021 fall.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 had all appropriate clinical interventions followed in this instance. The failure to report will be addressed as follows. The Facility Executive Director and/or designee will re-educate appropriate staff concerning what constitutes a reportable incident. Facility Executive Director and/or designee will review observation notes and incident reports daily for a period of 30 days then a sample selection once per week for a period of 3 weeks and once per month for a period of one quarter to ensure continued compliance with this standard."
Standard #:	22VAC40-73-325-B
Description:	Based on the review of facility records and interview conducted the facility failed to ensure that the fall risk rating was reviewed and updated after each fall. Evidence: Resident #1-Documented date of admission 04/02/2019 The facility?s Linden House Assisted Living Facility Observations document charting for September 2021 that was submitted for the inspector?s review on 10/08/2021 revealed that on 09/04/2021 the resident had a fall. Upon request the facility did not submit for the inspector?s review documented evidence that a fall risk ratings was reviewed or updated for the fall. During the 10/11/2021 telephone interview facility staff #1 stated that she could not locate the documentation.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 has had a comprehensive chart audit completed to include a fall risk rating and fall analysis. Facility Wellness Director and/or designee will conduct a comprehensive chart audit of facility to ensure all residents who have experienced a fall have an updated fall risk rating and accompanying fall analysis. Wellness Director will review observation notes daily for 30 days, then a sample selection once per week for 3 weeks then once per month for a period of one quarter to ensure continued compliance with this standard."
Standard #:	22VAC40-73-325-C
Description:	Based on the review of facility records and interviews conducted the facility failed to show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. Evidence: Resident #1-Documented date of admission 04/02/2019 Upon request the facility did not submit for the inspector?s review documented evidence that an analysis of what may have contributed to the 07/20/2021 and 09/04/2021 falls was completed and that interventions were initiated to prevent or reduce the risk of subsequent falls. During the 10/11/2021 telephone interview facility staff #1 stated that she could not locate the documentation.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 has had a comprehensive chart audit completed to include a fall risk rating and fall analysis. Facility Wellness Director and/or designee will conduct a comprehensive chart audit of facility to ensure all residents who have experienced a fall have an updated fall risk rating and accompanying fall analysis. Wellness Director will review observation notes daily for 30 days, then a sample selection once per week for 3 weeks then once per month for a period of one quarter to ensure continued compliance with this standard."
Standard #:	22VAC40-73-440-H
Description:	Based on the review of facility records and interviews conducted the facility failed to reassess a resident due to a significant change in the resident's condition. Evidence: Resident #1-Documented date of admission 04/02/2019 The resident?s 07/29/2021 hospice plan of care that the facility submitted for the inspectors review notes under the heading Safety Measures ?Requires total assist with ADLs?. 09/04/2021: The facility?s Linden House Assisted Living Facility Observations document notes ?Staff noticed resident is having some difficulty swallowing she ate very minimal dinner and was coughing a lot.? However, the facility reassessed the resident on 07/29/2021 (UAI) as needing no help with feeding/eating. The facility documentation submitted does not indicate that resident #1 has been appropriately reassessed.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 has had a comprehensive chart audit completed to include a reassessment with updates to her ISP and a comparison to ensure accuracy with hospice plan of care. Facility Wellness Director and/or designee will audit all resident ISPs who are enrolled with Hospice and compare services plans to ensure accuracy. All new Hospice admissions will be reviewed at time of admission by the Wellness Director and/or designee."
Standard #:	22VAC40-73-450-E
Description:	Based on the review of facility records, the facility failed to ensure that the individualized service plan was signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: Resident #1-Documented date of admission 04/02/2019 Facility records submitted for the inspectors? review note that on 08/20/2020 the resident was assessed as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The resident?s 07/29/2021 Individualized service plan (ISP) that was submitted for the inspectors? review revealed that the resident signed the ISP and not the legal representative. During the 10/08/2021 telephone interview the facility reported that the resident does have a Power of Attorney (POA).
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 has had a comprehensive chart audit completed to include a reassessment with updates to her ISP. Facility Wellness Director has reached out to resident #1 POA to request their signature on the ISP. All memory care charts will be audited to ensure ISP's are signed by the appropriate party in accordance with this standard. The Memory Care manager and/or designee will ensure all new or updated ISPs are signed by the appropriate party moving forward."
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interview conducted the facility failed to ensure that Individualized service plans were reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: Resident #1-Documented date of admission 04/02/2019 ? 08/20/2020: Facility records submitted for the inspectors? review note that the resident was assessed as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The resident?s 08/27/2020 and 07/29/2021 ISPs was not updated to note the resident?s need for a safe and secure environment. ? 07/29/2021: The resident?s hospice plan of care that the facility submitted for the inspectors review notes under the heading Safety Measures ?Requires total assist with ADLs?. The resident?s 07/29/2021 Individualized service plan (ISP) however notes in part ?Resident is able to wash hands, and face with prepared washcloth, resident will assist with upper body bathing. Staff to assist with lower body and back?. ? The facility did not update the resident?s 07/29/2021 ISP to note that the resident needs to be observed during the consumption of food to address ?the resident is having some difficulty swallowing she ate very minimal dinner and was coughing a lot.? The facility did not update the resident?s 07/29/2021 to note the resident?s most recent assessed needs.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 has had a comprehensive chart audit completed to include a reassessment with updates to her ISP in response any significant changes in condition and to include the need for a safe and secure environment. Facility Wellness Director and/or designee will audit all resident ISPs to ensure any significant changes in condition are appropriately reassessed and ISPs are accurate. Facility Wellness Director and/or designee, will sample audit ISP's on'ce per week for 3 weeks then once per month for one quarter to ensure future compliance with this standard."
Standard #:	22VAC40-73-680-D
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 04/02/2019 The facility?s medication administration record charting for August, September and October 2021 revealed that facility staff were documenting that resident prescribed medications were ?not onsite , not in the cart, not available; waiting delivery from pharmacy, medication in route to facility? indicating that the medications were not onsite and available for facility staff to administer to the resident per physician?s orders: August 2021: ? Risperidone 0.5MG to be administered one time a day: Sixteen different days that the medication was not administered ? Naproxen tablet 220MG to be administered every twelve hours: Six different days that the medication was not administered per physician?s orders. ? Morphine one 15MG tablet to be administered every twelve hours for pain: Facility staff documented three different days that the medication was not administered per physician?s orders. September 2021: ? Morphine one 15MG tablet to be administered every twelve hours for pain: Facility staff documented seven different days that the medication was not administered per physician?s orders. ? Acetaminophen 500mg- 2 caplets (100MG) to be administered two times a day for pain: Facility staff documented four different days that the medication was not administered per physician?s orders. October 2021: ? Morphine one 15MG tablet to be administered one time a day at bedtime for pain. Facility staff documented on 10/06, 07/2021 ?Med unavailable, waiting on delivery from Pharmacy and medication not in cart?. However, the same facility staff also documented that on 10/06/2021 at 8:10p.m the resident?s 0.5mg morphine PRN (as needed) was administered to the resident instead.
Plan of Correction:	FACILITY'S RESPONSE: "Resident #1 Facility Wellness Director and Nurse consultant completed a comprehensive chart audit on 19 OCT 2021 where all medications and orders were reviewed for accuracy and compliance with this standard. The facility Wellness Director and/or designee will conduct an all-clinical staff training to consist of Medication Administration competency and standards of practice for medication aides. The facility Wellness Director and/or designee will conduct a comprehensive audit offacility charts to review accuracy of medication administration compared to prescriber's instructions. After the initial audit the Wellness Director will conduct sample audits once per month for 3 months, then once per quarter for 3 quarters to ensure cont inued compliance."
Standard #:	22VAC40-73-680-K
Description:	Based on the review of facility records and interview conducted the facility failed to ensure that the use of PRN medications is prohibited, unless one or more of the allowed conditions exist. Evidence: Resident #1-Documented date of admission 04/02/2019 Facility staff documented that 0.5mg of morphine was administered to the resident on 10/06/2021 at 8:10p.m without authorization from the prescribing physician.
Plan of Correction:	FACILITY'S RESPONSE: "Facility Wellness Director and Nurse consultant completed a comprehensive chart audit for resident #1 where all medications and orders were reviewed for accuracy and compliance with this standard. Order received to discontinue the PRN Morphine at that time. The facility Wellness Director and/or designee will conduct a comprehensive review of all PRN medications to ensure a detailed order has been received that indicate the symptoms indicating use, the exact dosage and time frames the medication is to be given in a 24hr period and follow up directions if symptoms persist. All new PRN orders will be reviewed for this information by the Wellness Director for a period of 30day-s-- then random sample once weekly for 3 weeks then once monthly for one quarter to ensure continued compliance with this standard."