VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Waynesboro Manor
809 Hopeman Parkway
Waynesboro, VA 22980
(540) 942-2250

Current Inspector: Janice Knight (540) 430-9258

Inspection Date: March 4, 2019 and March 5, 2019

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 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 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.

Technical Assistance:

Answered questions from the administrator and supervisor and made recommendations on the following: 1) Five tubes of antiseptic ointment were in the facility first aid kit and two were almost empty and had expired. Make sure when new supplies are added the expired ones are removed. 2) Remind medication aides not to have their coffee on the medication cart. 3) Recommended adding evaporated or powdered milk to the emergency food supply. 4) When posting menus for all four weeks of the month, ensure the current week is on top. 5) Reviewed the current process for documenting meal consumption and recommended one staff clear the plates and another staff document the percentages rather than having both staff clear the plates and then both staff trying to document all percentages at the same time. This process should also ensure better accuracy. 6) Recommended adding a column to the fire drill model form that indicates actions taken to correct problems. Note: None of the drills since the last inspection had any noted problems. 7) All of the glucometer cases were labeled; however, most of the names were worn off the glucometers. Recommended the label maker be used to label the glucometers to prevent the names from wearing off over time. 8) Even though there were no problems or concerns discussed during the resident council meetings, reviewed the new requirement to provide in writing to the council, prior to the next meeting, the actions the facility took to correct any problems discussed in the meetings. Also recommended a copy of this notification be kept with the resident council meeting minutes. 9) Reviewed the new policies and made recommendations for change. Please ensure all changes are copied to this licensing inspector.

Comments:

An unannounced renewal inspection was conducted on 3/4/19 from approximately 7:40 am to 5:30 pm and 3/5/19 from approximately 7:15 am to 4:00 pm. A facility tour was immediately conducted of the interior and exterior of the facility. The facility was clean and free from any foul odors. Upon arrival there were two direct care staff/registered medication aides (RMAs) on duty and 29 residents in care. The posted menu and activities calendar accurately reflected this inspector's observations. Medication administration observations were completed with one RMA for three residents. All medication administration records and physicians' orders were reviewed and medications checked for these three residents. Individual interviews were conducted with residents, family members and staff. Seven resident (including one discharge), six staff and two contract staff records were reviewed. Selected sections of four additional resident and four staff records were also reviewed. The areas of noncompliance included postings, hospice agreements, resident agreements, individualized service plans, dietary reviews and oxygen emergency preparedness information. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-290-B
Description:	Based upon observations and an interview, the facility failed to ensure the name of the staff person in charge (SIC) was posted and conspicuous to the residents and the public. Evidence: 1) Upon arrival at 7:40 am, the licensing inspector (LI) observed the facility had a white board posted on the wall in the front room/hallway. The words "Staff in Charge" were on the board; however, no name was listed. The rest of the board was blank and the SIC information was not posted in any other public area of the facility. 2) On 3/4/19, the LI interviewed the registered medication aide on duty and she stated the supervisor/SIC must have forgotten to put her name on the board.
Plan of Correction:	Administrator and supervisor met on 3/4/19 with all staff to review SIC posting policy. The board being used for the posting of the SIC since 2/1/18 was updated on 3/4/19 to reflect the current SIC and has been updated with each change of SIC since. When the SIC enters the building to work, they are responsible for updating the board with their name. All staff have been asked to ensure the board is current at all times. Administrator and supervisor will monitor the board on each day worked.
Standard #:	22VAC40-73-310-M
Description:	Based upon an interview, the facility failed to ensure a written agreement was completed and on file for two of the three hospice programs that provided care in the facility. Evidence: On 3/4/19, the LI requested the written agreements for the three hospice programs that provided services to the current residents; however, the administrator stated she only had an agreement with one of the providers.
Plan of Correction:	Administrator developed a Waynesboro Manor Hospice Provider contract on 3/8/19. Administrator submitted the contract to both hospice agencies which were without written agreements and are currently serving Waynesboro Manor residents. A deadline of 4/1/19 was given to the hospice agencies for review, approval and signature of the contracts. Administrator will follow up with the hospice agencies until the signed contracts are received. Administrator will require any new hospice agency requesting to provide services to a Waynesboro Manor resident to sign a contract prior to beginning services.
Standard #:	22VAC40-73-390-A
Description:	Based upon documentation and an interview, the facility failed to ensure five of the seven resident agreements reviewed had all of the required information. Evidence: 1) The written agreements for the following residents did not include the refusal of release of information: C (admitted 3/2/19 and signed 2/25/19); D (admitted 12/11/18 and signed 12/7/18); F (admitted 7/25/18 and signed 7/25/18); G (admitted 2/1/19 and signed 1/29/19); I (admitted 10/13/18 and signed 10/12/18). 2) On 3/5/19, the LI interviewed the administrator who stated the release of information was included in the agreement; however, the refusal for release of information had not been added.
Plan of Correction:	Administrator added the refusal for release of information to the release of information section of the resident agreement on 3/6/19. Residents admitted to the Waynesboro Manor since 2/1/18 were given a copy of the amended release of information section and initialed receipt of the new policy for record retention. Administrator will ensure all future residents will receive the revised resident agreement to include the refusal of release of information update.
Standard #:	22VAC40-73-450-F
Description:	Based upon observations, documentation and an interview, the facility failed to ensure five of the eleven individualized service plans IISPs) reviewed included all of the residents assessed needs and services provided. Evidence: 1) The uniform assessment instrument (UAI) completed on 2/19/19 for resident C indicated mechanical help and supervision for bathing and no help needed for stair climbing; however, the ISP completed on 3/1/19 only listed mechanical help needed for bathing and mechanical help and supervision needed for stair climbing. 2) The UAI (completed 11/28/18) for resident D indicated mechanical help and assistance needed for stair climbing; however, the ISP (completed 12/13/18) listed mechanical help and supervision. 3) The UAI (completed 11/6/18) for resident E indicated disorientation to some spheres some times (place and time); however, this information was not included on the ISP (completed on 11/6/18). 4) On 3/5/19, the LI interviewed resident G and observed a raised toilet seat in the resident's bathroom. The UAI (completed on 1/29/19) indicated mechanical help and supervision needed for toileting; however, this need was not included on the ISP (completed on 2/4/19). 5) The ISP (completed 12/1/18) for resident H did not include hospice services.
Plan of Correction:	Supervisor corrected all ISPs and UAIs within this violation on 3/5/19. Supervisor will continue to create ISPs and UAIs. Administrator will review all ISPs and UAIs monthly to ensure accuracy. Supervisor updated resident C's UAI on 3/5/19 to indicate no help for bathing needed and mechanical help and supervision needed for stair climbing. Supervisor updated resident C's ISP on 3/5/19 to indicate no help needed for bathing. Supervisor updated resident D's ISP on 3/5/19 to indicate mechanical help and physical assistance needed for stair climbing. Supervisor updated resident E's ISP on 3/5/19 to indicate staff will help resident with place and time. Supervisor updated resident G's ISP on 3/5/19 to indicate mechanical help and supervision needed for toileting, including raised toilet seat and grab bar. Supervisor updated resident H's ISP on 3/5/19 to indicate services being received from hospice.
Standard #:	22VAC40-73-620-A
Description:	Based upon documentation and an interview, the facility failed to ensure a dietary review was completed at least once every six months for all residents on a special diet. Evidence: 1) The last documented dietary review on file was completed on 5/18/18. 2) On 3/5/19, the LI interviewed the administrator who confirmed this review was the only one completed since the last inspection.
Plan of Correction:	Administrator contacted a new dietician on 3/13/19 and has requested the dietary review be scheduled by 3/22/19 and conducted by 4/1/19. Administrator will ensure a dietary review is conducted every six months for all residents on special diets.
Standard #:	22VAC40-73-700-6
Description:	Based upon documentation and an interview, the facility failed to ensure the information required for oxygen therapy was included in the emergency preparedness plan (EPP). Evidence: 1) The most current emergency preparedness plan did not include the checklist of information required to meet the identified needs of the residents who require oxygen therapy. 2) On 3/5/19, the LI interviewed the administrator who stated this information had not been added to the updated EPP.
Plan of Correction:	Administrator added the required checklist of information on 3/13/19 to the EPP for residents who require oxygen therapy. Administrator will continue to review the EPP quarterly for any updates needed and submit to local emergency coordinator for review and approval.