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: Aug. 31, 2022 , Sept. 1, 2022 , Sept. 15, 2022 and Sept. 23, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal An unannounced renewal inspection was conducted by two inspectors on 8-31-22 (Ar 07:40/dep 5:20 p.m.) The facility census was 68. A tour of the facility was conducted, a medication pass observation was conducted, emergency preparedness items reviewed, including the first aid kits; resident and staff interviews and records were reviewed, the breakfast meal on the assisted living unit was reviewed. A preliminary exit meeting was conducted with the administrator, the administrator in training, the social work director, nursing director and a staff from staff development. Requested documents were asked to be sent by close of business on 9-1-22 (facility computer system for training records not working properly). The acknowledgement form was signed and dated by the administrator. The final exit meeting will be scheduled. 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 Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-220-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure all requirements were met when private duty personnel who are not employed by a licensed home care organization provide direct care or companion services to resident in an assisted living facility. Evidence: 1. On 8-31-22, the record for the private duty companion for resident #8 did not document the frequency of services to be delivered to the resident. The orientation checklist was not signed by the private duty companion. There was no criminal history report in the record for the companion. 2. On 8-31-22, staff #2 acknowledged the facility did not have all of the required information and documentation for the private companion for resident #8.
Plan of Correction:	1. Assisted Living Administrator in Training (Home Care Companion Leader) contacted private duty companion to obtain care plan to include frequency of service, criminal history report, and signed orientation checklist for identified companion. 2. An audit of all private duty companions will be conducted to ensure that orientation checklists are signed, criminal history reports are filed and care plans with frequency of services are documented. 3. Assisted Living Administrator or designee will update the orientation checklist to ensure timely completion of documentation for private duty companions. 4. A random audit of residents with private duty will be conducted monthly x 3 months to ensure all documentation has been filed. 5. Progress of new process will be reported to QA Committee. Person Responsible: Assisted Living Administrator by October 1, 2022
Standard #:	22VAC40-73-250-D
Description:	Based on records reviewed and staff interviewed, the facility failed to ensure the subsequent tuberculosis (TB) evaluations and reports were signed and dated by a qualified evaluator for four individuals. Evidence: 1. On 8-31-22, staff 2 and #5?s subsequent tuberculosis (TB) screening dated 2-3-22 was not signed by a qualified evaluation. Staff #6?s subsequent TB screening dated 2-1-22 and Staff #10?s subsequent TB screening dated 1-26-22 was not signed and dated by a qualified evaluator. 2. On 8-31-22, staff #2 acknowledged the aforementioned individuals subsequent TBs were not signed and dated by a qualified evaluator.
Plan of Correction:	1. HR Director / HR Assistant updated records of identified team members to ensure the current TB evaluations and reports are signed and dated by a qualified evaluator for the individuals identified. 2. HR team to review all AL MS team member records to ensure appropriate TB screening evaluations are signed and dated by a qualified evaluator. 3. HR team re-educated on ensuring that all future documents are signed and dated by a qualified evaluator. 4. Random audits will be conducted by Assisted Living Administrator or designee monthly for three months to ensure TB screenings are signed and dated properly. 5. Progress of new process will be reported to QA Committee. Person responsible: HR Director by October 31, 2022
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs. Evidence: 1. On 8-31-22, resident #3?s August 2022 medication administration record (MAR) documented resident prescribed Mirtazapine. A review of the prescribers orders on 8-31-22 documented prescribers e-signed Mirtazapine on 4-29-22. A review of the resident?s record did not include a treatment plan for this psychotropic medication. 2. On 9-15-22, staff #3 acknowledged the facility did not have a treatment plan for psychotropic medication prescribed for the aforementioned resident.
Plan of Correction:	1. Nurse manager requested psychotropic treatment plan from prescriber for resident identified. 2. Nurse manager conducted a full audit for AL/MS residents to ensure treatment plans for psychotropic medications were completed for all other residents on psychotropic meds. 3. Nurse manager developed an AL and MS neighborhood binder for use with providers who prescribe medications which require psychotropic treatment plans. Nurse manager educated nursing team on how to identify medications which require psychotropic treatment plans, how to request plan, and what to do when plan is received. 4.Random audits will be conducted by nurse manager monthly for 3 months to ensure all medications which require psychotropic treatment plans have the specified plans in the resident?s electronic medical record. 5. Progress of new process will be reported to QA Committee. Person responsible: Nurse Manager / AL Administrator by October 7, 2022.
Standard #:	22VAC40-73-320-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure a risk assessment for tuberculosis (TB) was completed annually for a resident as evidenced by the completion of a current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 8-31-22, resident #5?s tuberculosis information was dated 9-14-17; resident?s date of admission noted as 9-15-16. 2. On 8-31-22, resident #1?s record did not have documentation of an annual risk assessment for TB as required. 3. On 8-31-22, staff #3 and #4 acknowledged the aforementioned residents? record did not have documentation of a current TB assessment.
Plan of Correction:	1. Nurse manager to ensure that current TB screening is completed on identified residents. 2. Nurse manager or designee will review and ensure that a current TB test or screen is on file for all other AL/MS residents and done annually thereafter. 3. Nurse manager educated nursing team on ensuring TB assessment for all new admissions are completed and entered into resident?s electronic medical record. 4. Random audits will be conducted monthly by nurse manager for three months to ensure TB screenings and annual orders for TB Screens are in the resident?s electronic medical record. 5. Progress of new process will be reported to QA Committee. Person responsible: Nurse Manager / AL Administrator by October 31, 2022
Standard #:	22VAC40-73-325-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the fall risk rating was reviewed and updated at least annually. Evidence: 1. On 8-31-22, resident #1?s record did not include the most recent fall risk rating. The risk rating in the record was dated 5-10-21. 2. On 8-31-22, staff #4, acknowledged the aforementioned residents? fall risk rating was not updated annually as required.
Plan of Correction:	1. Nurse manager to ensure current fall risk rating assessment on the identified resident is completed. 2. Nurse manager to ensure current fall risk rating assessments are completed as required on all current residents. 3. Nurse manager re-educated nursing staff to ensure that annual fall risk rating assessment is completed for all new admissions. 4. Random audits will be conducted monthly by nurse manager for three months to ensure TB screenings and annual orders for TB Screens are in the resident?s electronic medical record. 5. Progress of new process will be reported to QA Committee. Person responsible: Nurse Manager / AL Administrator or designee by October 31, 2022
Standard #:	22VAC40-73-440-D
Description:	Based on record review and staff interview, the facility failed to ensure for private pay individuals the uniform assessment instrument (UAI) was completed as required by 22 VAC30-110 for four of eight residents? records. Evidence: 1. On 8-31-22, resident #1?s uniform assessment instrument (UAI) dated 6-20-22 was not signed by the administrator or designee. 2. Resident #2?s uniform assessment instrument (UAI) in the record did not contain the date of the assessment. The document also was not signed by the administrator or designee. 3. Resident #6?s UAI dated 6-3-22 was not signed by the administrator or designee. 4. Resident #8?s UAI dated 12-21-21 was not signed by the administrator or designee. 5. On 8-31-22, staff #3 and #4 acknowledged the aforementioned UAI was not completed as required.
Plan of Correction:	1. Assisted Living Administrator to ensure that updated UAIs include signatures on the 5 identified resident files. 2. The Director of Social Services and Assisted Living Administrator or designee will review the remaining UAIs for residents in AL/MS to ensure appropriate signatures are completed. 3. Assisted Living Administrator in Training requested an EMR system notification for UAI signatures to ensure all future signature requirements are addressed timely. 4. Random audits will be conducted monthly for three months by Director of Social Services and Assisted Living Administrator in Training for completion of signatures on UAI?s. 5. Progress of the new process will be reported to QA Committee. Person responsible: Assisted Living Administrator or designee / Director of Social Services by October 31, 2022.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs for five of eight records reviewed. Evidence: 1. On 8-13-22, resident #1?s individualized service plan (ISP) dated 12-22-20 did not include the resident?s allergy to tape as documented on the resident?s physical examination dated 9-13-20. The ISP documented no known medical/food/environmental allergies. Resident?s physician order sheet (POS) dated 8-31-21 documented physical therapy (PT) evaluation dated 3-3-21; continued skilled physical therapy 3-26-21, 5-26-21, 6-16-21 and 7-22-21. The record included physical therapy notes from 3-3-21 thru 5-20-21. The POS documented occupational therapy (OT) evaluation 3-22-21, clarification order 5-17-21, clarification order 7-23-21 and 8-26-21. Speech therapy (ST) effective on 7-20-21. 2. Resident #3?s UAI dated 5-2-22 documented dressing assessed as mechanical and human help (supervision). The ISP documented the resident required mechanical help and human help (physical assistance) with dressing. The ISP documented resident is a Do Not Resuscitate (DNR), the record did not have a signed physician?s order for a DNR. The resident has a side bed rail, this support device was not on the resident?s ISP. 3. Resident #4?s uniformed assessment instrument (UAI) dated 8-3-21 documented medication to be administered by facility staff. However, the physician?s order dated 8-31-21 and the July 2021?s medication administration record (MAR) documented resident keep medication at bedside and self- administers Clotrimazole and Preparation H. The UAI laundry need document help needed. The ISP dated 8-3-21 documented resident, ?does not require assistance? and ?resident takes care of own laundry?. The resident?s Oxygen Therapy did not include the oxygen source, delivery device and the flow rate deemed therapeutic for the resident. 4. Resident #6?s UAI dated 6-3-22 dressing assessed as human help only. The ISP documented resident required mechanical assistance for dressing. 5. Resident #7?s UAI dated 6-23-22 bathing assessed as mechanical help only. The ISP documented the resident required mechanical and human assistance. Dressing was assessed as human help only. The ISP documented the resident required mechanical devices. Toileting assessed as mechanical assistance. The ISP documented resident required staff assistance. 6. Staff #3 and #4 acknowledged the resident?s ISP did not contain all assessed needs.
Plan of Correction:	1. Director of Social Services corrected the 5 identified resident?s ISPs to include all assessed needs. 2. The Director of Social Services, AL Administrator in Training and Nurse Manager will conduct audits of all UAI / ISPs for accuracy using a triple check method. 3. A class for nursing team members to be trained/certified on how to complete the Uniform Assessment Instrument and the Individual Service Plans will be scheduled by October 31, 2022. 4. Random audits of resident?s UAI and ISP?s will be conducted by Director of Social Services, AL Administrator in Training and Nurse Manager after completion of UAI / ISP training for nursing team. 5. Progress of new processes will be reported to QA Committee. Person responsible: Director of Social Services / AL Administrator / Nurse Manager by October 31, 2022
Standard #:	22VAC40-73-450-D
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living and the licensed hospice organization shall communicated and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). Evidence: 1. On 8-31-22, resident #2?s record was identified as one receiving hospice services. A review of the resident?s ISP with staff #3, the document did not include the hospice services being provided. The resident?s record noted hospice services began 8-16-22. 2. On 8-31-22, staff #3 acknowledged the aforementioned resident?s record did not include the hospice services provided.
Plan of Correction:	1. Director of Social Services corrected identified resident?s ISP to reflect coordination of hospice services. 2. Director of Social Services and Nurse Manager clarified plan between the community and hospice service provider to incorporate hospice services with the community?s service plans. 3. Nurse manager will ensure that hospice services are included in care plans for all hospice residents. 4. Director of Social Services and Nurse Manager will complete random audits monthly for 2 months to ensure all resident?s receiving hospice services have coordinated service plans. 5. Progress of new processes will be reported to QA Committee. Person responsible: Director of Social Services / Nurse Manager by October 31, 2022
Standard #:	22VAC40-73-580-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure when any portion of an assisted living facility is subject to inspection by Virginia Department of Health, the facility shall be in compliance with those regulations as evidenced by an initial and subsequent annual reports from the Virginia Department of Health. Evidence: 1. On 8-31-22, the facility health inspection report was dated 2-17-21. 2. Staff #1 acknowledged the facility did not have a current health inspection.
Plan of Correction:	1. Assisted Living Administrator requested update on status of current health inspection. 2. AL Administrator will continue to request regular updates for 2022 annual health inspection until inspection is completed. 3. AL Administrator will create a calendar reminder to ensure future Health Inspections are completed timely or communications with the health department are documented more frequently. 4. Progress of new process will be reported to QA committee Person responsible: Assisted Living Administrator by October 14, 2022
Standard #:	22VAC40-73-680-K
Description:	Based on observation, record reviewed and staff interviewed, the facility failed to ensure when medication aides administer the PRN medications, the facility shall ensure the resident?s physician or other prescriber detailed medication order include the exact dosage for the medication to be administer. Evidence: 1. On 8-31-22 during the medication pass observation with staff #5, resident #1?s September 2022 medication administration record (MAR) noted the powder to be mixed with 4 to 8 ounces of fluid. 2. On 8-31-22, staff #3 acknowledged the aforementioned resident?s Miralax order was not written for the exact ounces of fluid.
Plan of Correction:	1. Nurse manager will request new orders for identified residents with medications that contain ranges to replace with exact dosages. 2. Nurse Manager or designee will review orders for all other residents to ensure medications do not contain ranges. 3. Nurse manager will educate nursing team and providers on requirement of orders with exact dosages. 4. Nurse Manager or designee will complete random audits for 30 days to ensure all new residents orders contain exact doses. 5. Progress of new processes will be reported to QA Committee. Person responsible: Nurse Manager / AL Administrator by October 31, 2022
Standard #:	22VAC40-90-40-B
Description:	Based on record review and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day of employment for a staff. Evidence: 1. Prior to the 30th day of employment, the facility did not have documentation of the criminal history record report for staff #9. Staff?s date of hire documented as 8-30-21 and the criminal history report dated 8-31-22 2. On 8-31-22, staff #1 acknowledged the facility did not obtain on or prior to the 30th day of employment a criminal history record for a new employee.
Plan of Correction:	1. HR director will complete a full audit of AL/MS team members (clinical and non-clinical) to ensure criminal history record was obtained. 2. HR Director will update checklist to ensure that future criminal history records are audited by the HR Director for accuracy/completion prior to sign-off. 3. HR Director will educate HR team on new process to ensure criminal history reports are obtained timely. 4. HR team will conduct audits monthly for three months and report the findings to the Assisted Living Administrator. 5. Progress of new process will be reported to QA Committee. Person Responsible: HR Director by October 15, 2022