VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Newport News Baptist Retirement Community DBA The Chesapeake
955 Harpersville Road
Newport news, VA 23601
(757) 223-1635

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: Sept. 8, 2020

Complaint Related: No

Areas Reviewed:

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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

This inspection 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. A renewal inspection was initiated on 8-17-20, 8-18-20, 8-19-20, 8-21-20, 8-23-20, 8-24-20 and concluded on 8-26 -20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 67. The inspector e-mailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, physician's orders, staff schedule, healthcare oversight, health department inspection, fire and emergency drills, and new hire since last renewal inspection date, sworn statement/affirmation and criminal history record report. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility. Inspector Signature Facility/Program Representative Signature Date: Date:

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on record review and staff interview, the facility failed to ensure within four months of starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment for two staff. Evidence: 1. During the remote renewal inspection, a review of staff #2's record on 8-19-20, interview with staff #1 on 8-21-20 and 8-26-20, noted the following cognitive training hours listed on the facility's training transcript submitted: 5 hours of cognitive training on 5-29-19. Staff #2?s date of hire was documented as 5-28-19. 2. A review of staff #3?s record on 8-19-20, interview with staff #1 on 8-21-20 and 8-26-20, noted the following cognitive training hours listed on the facility?s training transcript submitted: 5 hours of cognitive training on 3-12-19. Staff #3?s date of hire was documented as 3-11-19. 3. On 8-26-20 during the exit interview, staff #1 acknowledged staff training hours did not meet requirement within required time.
Plan of Correction:	1. New Staff will receive 10 hours of cognitive impairment training within 4 months of their start date. Person Responsible: Staff Dev. Coord/ HR 2. HR and Staff development team will be educated on requirements to be met for all team members.Person Responsible: Administrator 3. An audit of training for all direct care team members will be conducted to ensure required cognitive impairment training hours within 4 months of start date have been met. Person Responsible: HR Staff 4. Audit findings to be reported to the AL Administrator. Person Responsible: QA Nurse
Standard #:	22VAC40-73-1140-E
Description:	Based on record review and staff interview, the facility failed to ensure within the first month of employment, staff other than the administrator and direct care staff who will have contact with residents in the special care unit shall complete two hours of training on the nature and needs of residents with cognitive impairments due to dementia for two staff. Evidence: 1. During the remote renewal inspection, a review of staff #4's record on 8-19-20, the interview with staff #1 on 8-21-20 and 8-26-20, noted the following cognitive training hours listed on the facility's training transcript submitted: 1 hour of cognitive training on 10-28-19. Staff #4?s date of hire was documented as 10-28-19. 2. A review of staff #5?s record on 8-19-20, interview with staff #1 on 8-21-20 and 8-26-20, noted the following cognitive training hours listed on the facility?s training transcript submitted: 1 hour of cognitive training on 10-28-19. Staff 5?s date of hire was documented as 10-28-19. 3. On 8-26-20 during the exit interview, staff #1 acknowledged staff training hours did not meet requirement within required time.
Plan of Correction:	1. New staff will receive 2 hours of training on cognitive impairment within the first month of employment. Person responsible: 2. HR and Staff Development team will be educated on ensuring the requirement is met for all team members. 3. An audit of all direct care team members conducted to ensure required cognitive impairment training New staff will receive 2 hours of training on cognitive impairment within the first month of employment. Person Responsible: Staff Dev. Coord/HR Team/ Admin
Standard #:	22VAC40-73-290-A
Description:	Based on documents reviewed and staff interviewed, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. During the remote renewal inspection, a review of the dietary staff schedule submitted on 8-24-20 noted the first name of staff and no job classification for the names on the schedule. The document also did not include the shift/times/ hours worked by staff. 2. A review of the housekeeping schedule submitted on 8-24-20 did not include the job description and did not indicate the hours/time/shift worked by staff. 3. A review of the nursing department schedules presented did not indicate who was in charge in the absence of the administrator at any given time. 4. Staff #1 during the exit interview on 8-26-20, the staffing schedules submitted did not include all required information.
Plan of Correction:	1. Full names or Last initials/ job titles and shifts worked for dietary and housekeeping staff were added to current schedule in addition to person in charge on nursing schedule. Person responsible: Department Director/ Administrator 2. Scheduling template changed to include all required information for all departments. Person responsible: Department Director 3. Scheduler and supervisors will be educated on ensuring requirements of schedule are met. Person responsible: AL Administrator 4. Random audits of schedules to occur quarterly to ensure information is retained on staff schedules Person responsible: AL Administrator or designee
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with prohibitive conditions such as psychotropic medication without a treatment plan for two residents. Evidence: 1. During the remote renewal inspection, a review of resident #1?s record on 8-19-20 and interview with staff #1 on 8-21-20 and 8-26-20, the physician?s order dated 8-18-20 noted the resident is prescribed Mirtazapine (Remeron) for depression. A review of the resident?s July 2020 medication administration record (mar) also noted administration of Mirtazapine. On 8-21-20, a request for the treatment plan for the psychotropic medication was requested from staff #1. On 8-23-20, progress notes were received and reviewed. The progress note dated 7-6-20 noted Mirtazapine listed as one of the medications, however, no diagnosis was noted. Further review of the progress note indicated past history of ?major depressive disorder?; neurological/psychiatric noted indicated, ??patient, awake, alert, and oriented?. 2. A review of resident #2?s record on 8-19-20 and interview with staff #1 on 8-21-20 and 8-26-20, the admission?s physical examination signed 1-4-20 noted Zoloft, for anxiety. Further review of the document noted, the section with the question regarding if individual have need for following condition or care need for psychotropic medication without diagnosis and treatment plan, the section is checked ?no?. A review of the resident?s July 2020 medication administration record (mar) noted resident #2 administered Zoloft. On 8-21-20, a request for the treatment plan for the psychotropic medication was requested from staff #1. On 8-24-20 requested again, however, e-mail dated 8-25-20 indicated facility unable to obtain document from physician. 3. On 8-26-20 during exit interview, staff #1, acknowledged not having treat plan for psychotropic medication for two residents.
Plan of Correction:	Treatment plans obtained for residents #1 and #2. Clarification for diagnosis also obtained.Person responsible: Nurse Manager 2. Audit conducted to ensure treatment plans and diagnoses are in place for all residents on psychotropic medications. Person responsible: Staff Dev Coord. 3. Staff educated on ensuring proper diagnosis and treatment plans obtained as needed upon admission and when new orders are received for psychotropic meds. Person responsible: Staff Dev Coord. 4. Quarterly audits will be conducted to ensure treatment plans are in place for residents on psychotropic medications. Person responsible: QA Nurse 5. Audit findings to be reported to QA Committee. Person responsible: QA Nurse
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure individualized service plan (ISP) included all assessed needs for four resident. Evidence: 1. During remote renewal inspection, a review of resident #1?s uniformed assessment instrument (uai) dated 6-30-20 indicated stairclimbing need assessed as not performed, however, a review of the individualized service plan (ISP) submitted on 8-19-20 did not include assessed need. Further review reveal the ISP was missing pages. On 8-21-20 during interview with staff #1, missing pages 2-4-6 was requested and received. Review of the received ISP pages did not include stairclimbing assessed need. A review of the resident?s physician order noted NAS diet/ chopped meats; however, the uai indicated no need for eating/feeding and the ISP did not include assessed need noted on the physician order... A review of the resident?s physician?s orders dated 8-18-20 noted occupational therapy (OT) services order on 7-23-20, however, need was not on the ISP. 2. A review of resident #2?s physician?s examination dated 12-31-19 noted resident allergic to tape. A review of the resident?s individualized service plan (ISP) submitted on 8-19-20 did not include allergy information. The ISP noted under ?Category 18 Allergies??.. resident had no known allergy. 3. A review of resident #3?s uniformed assessment instrument (uai) dated 4-28-20 noted bathing assessed as mechanical help/physical assistance/ human/help (mh/pa/hh), however, the individualized service plan (ISP) submitted noted under ?Category 1 Bathing.... mechanical help only?. The physician?s examination dated 4-27-20 noted diet- ?.mechanical soft with ground meats?.liquids via sippy cup?, however, this assessed need is not on the ISP. Walking need assessed on the uai as not performed, however, need is not on the ISP. Physician?s order dated 4-27-20 noted physical therapy/ occupational therapy/ and speech therapy (PT/OT/ST), however, these needs are not on the ISP. 4. A review of resident #4?s uniformed assessment instrument (uai) dated 4-22-20 noted dressing need assessed as mechanical help/human help/physical assistance, however, the individualized service plan (ISP) submitted on 8-19-20 with additional ISP pages (2-4-6) submitted on 8-21-20 noted under ?Category 2- Dressing??..mechanical help/ human help, however, the services provided does not include what mechanical help is provided. Toileting assessed and noted on the ISP under ?Category 3- Toileting??.mechanical help and human help (supervision). However, the services provided noted human help (physical assistance). Further review of resident #4?s record included a physician?s order dated 7-23-20 ?eval and tx for knee pain, mobility?. A review of the ISP did not include therapy services. Resident #4?s physical examination signed on 2-28-18 noted the following allergies: Atorvastatin, Simvastatin, Sulfacetamide and Decongestants. Licensing inspector reviewed allergy with staff #1 on 8-21-20. 5. Staff #1 acknowledged resident?s ISP did not include all assessed needs during interviews on 8-21-20 and 8-26-20.
Plan of Correction:	1. UAIs and ISPs for residents #1-4 were updated to reflect current needs. Person responsible: Nurse Manager/ AL Administrator 2. Audit conducted to ensure all UAI and ISPs reflect the current needs of all residents. Person responsible: Staff Dev Coord. 3. Staff will be educated on proper completion of UAIs and ISPs. Person Responsible: Staff Dev Coord. 4. Quarterly audits will be conducted to ensure UAIs and ISPs are current and includes all assessed needs. Person Responsible: QA Nurse 5. Audit findings to be reported to QA Committee. Person Responsible: QA Nurse
Standard #:	22VAC40-73-490-D
Description:	Based on document reviewed and staff interview, the facility failed to ensure the health care oversight was completed as required. Evidence: 1. During the remote renewal inspection, a review of the healthcare oversight document submitted indicated did not included the specific residents for whom the oversight was provided. The dates of the review was January 1, 2020 and ended June 30, 2020. However, the staff performance was conducted April 15- June 16, 2020; staff training was noted January- June 16, 2020, infection control review March 16- June 16, 2020 and medication management compliance dated June 16, 2020. 2. Healthcare oversight reviewed with staff #1 on 8-26-20, staff acknowledged the document was not completed as required and not certified by the health professional who provided the health care oversight report.
Plan of Correction:	1. Names of residents and staff will be included on the Oversight report. Person responsible: Staff Dev/Coordinator/ IP Nurse 2. The Healthcare oversight report will be amended to quarterly reviews. Another signature line will be added to the model form for the health professional to certify that all requirements are met for the report. Person responsible: IP Nurse 3. Health professional educated on the requirements of completing the Oversight report. Person responsible: AL Administrator 4. All Oversight records will be reviewed for proper signature on a quarterly basis. Person responsible: AL Administrator or designee
Standard #:	22VAC40-73-680-C
Description:	Based on record review and staff interview, the facility failed to ensure the medication administration record noted the facility?s dosage time in accordance with the facility?s dosage policy. Evidence: 1. During the remote renewal inspection, a review of resident #3?s July 2020 medication administration record (mar), the mar did not include the dosing time for the following medications: (a) Galantamine ER, (b) Loratadine, and (c) Ergocalciferol noted time as ?DAY? and (b) Melatonin and Trazadone noted time as ?EVE?. 2. On 8-21-20 during interview with staff #1, staff acknowledged the dosing time was not listed for the aforementioned medications on resident #3?s July 2020 mar.
Plan of Correction:	1. Dosing time corrected on MAR for Resident #3. Person responsible: Nurse Manager 2. Dosing times for all residents will be reviewed for accuracy. Person responsible: Nurse Manager 3. Staff will be educated on entering the proper dosing times for medications. Person responsible: Staff Dev. Coord./ AL Administrator 4. Quarterly audits will be conducted to ensure that all orders on MARs have proper dosing times. Person responsible: QA Nurse 5. Audit findings to be reported to QA Committee. Person responsible: QA Nurse
Standard #:	22VAC40-73-680-I
Description:	Based on record review and staff interview, the facility failed to ensure the medication administration record (mar) included all required information for three of four residents. Evidence: 1. During the remote renewal inspection, a review of resident #1?s medication administration record for July 2020 was missing staff initials on the following dates: (a) 7-26-20: Lidocaine patch 8:00 a.m; (b) 7-27-20: Gabapentin- 12:00 pm; and (c) 7-30-20: Nystatin- 16:00 pm, Eliquis-17:00 pm, Gabapentin-17:00 pm, and Lidocaine patch, Mirtazapine, Atorvastatin- 21:00 pm. 2. A review of resident #2?s July 2020 medication administration record (mar), diagnosis, condition or specific indications for administration of drug or supplement was missing for (a) Certavite- Antioxidant and (b) Memantine (this item is noted on the mar five varying dosage and time, however, no diagnosis is noted. 3. A review of resident #3?s July 2020 medication administration record (mar) was missing staff initials on the following dates: (a) 7-1-20: Mirtazapine- 17:00 pm and (b) 7-3-20 at 8:00 pm: Buspirone, Lipitor, Namenda and (c) 7-3-20: Ativan-19:00 pm. Further review of resident #3?s physician?s order dated 4-27-20, the following medications were missing the diagnosis, condition or specific indications for administration of drug or supplement for medications administered prior to resident?s transfer date 7-22-20: Buspar, Galantamine ER, Metoprolol Tartate, Eliquis, Lipitor, Losartan, Sertraline, Omeprazole, Ergocalciferol, Namenda, Melatonin and Trazadone. 4. A review of resident #4?s July 2020 medication administration record (mar) was missing staff initials on 7-20-20: Amlodipine, Budesonide, Doxycycline Hyclate, Eliquis, Metoprolol Tartrate, Stiolto Respimat, Januvia and Clonidine HCL.
Plan of Correction:	1. Staff educated on signing of MARs at time of administration of medication. Person Responsible: Nurse Manager 2. Supervisor to review MARs prior to end of shift. Person Responsible: Nurse Manager 3. Random Audits will be conducted weekly for 30 days and monthly thereafter to ensure MARs are signed. Person Responsible: Staff Dev. QA Coord/ AL Nurse Manager 4. Audit findings to be reported to QA Committee. Person Responsible: QA Nurse