VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Radford
7486 Lee Highway
Radford, VA 24141
(540) 639-2411

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: May 6, 2019

Complaint Related: No

Areas Reviewed:

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

Comments:

Two licensing inspectors conducted a one day unannounced focused monitoring licensing inspection at Commonwealth Senior Living-Radford on 05/06/2019. The monitoring inspection began at 10:35 am and concluded at 12:05 pm. The purpose of this inspection was to determine compliance and correction of previously cited violations. A tour of the building was conducted, resident files were reviewed and staff files were reviewed. As a result of this inspection, three violations are being cited, all of these are repeat violations. An exit meeting was conducted with the facility administrator on 05/06/2019 and at that time the opportunity was given to find items that could not be located in files. Please provide a plan of correction to include the date to be corrected for each violation cited and return a signed and dated copy of the violation notice back to your licensing inspector within 10 days (06/18/2019) of receipt. If you have any questions or concerns, contact your inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-120-B
Description:	Based on staff records' review, the facility failed to orient and train new staff on the required components within the first seven working days of employment. EVIDENCE: Staff #1 was a new hire and did not receive orientation on the following sections. 1. The purpose of the facility, 2. The servcies provided, 3. The daily routines, and 4. Specific duties and responsibilities of their position.
Plan of Correction:	Executive Director re-educated the Business Office Manager on the required components of orientation within the first seven working days of employment. Staff #1 will participate in the sections noted and the orientation will be documented. Business Office Manager will audit personnel files at a minimum of twice monthly to ensure compliance. Executive Director or designee will audit personnel files post hire to ensure continued compliance. [sic]
Standard #:	22VAC40-73-260-A
Description:	Based on staff interview and staff records, the facility failed to ensure each direct care staff member maintained a current certification in first aid. EVIDENCE: 1. Staff #8 stated the facility was not yet in full compliance with this standard. 2. Staff #8 was unable to provide first aid certification for Staff #s 2-7. A total of six staff without current first aid certification.
Plan of Correction:	First Aid completed for Staff #2-7. Business Office manager will review all new hire documents prior to the associate beginning orientation to determine training needs. Associates needed first aid certification will be scheduled to attend the training within the first 60 days of employment. The Executive Director or designee will audit a minimum of 5 associate's personnel files per month to ensure continued compliance. [sic]
Standard #:	22VAC40-73-450-C
Description:	Baed on documentation review, the facility failed to ensure Individualized Service Plans(ISP) contained a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them. EVIDENCE: 1. Resident #1's ISP indicates dressing requires physical assistance but does not specify what type is needed.
Plan of Correction:	The Individualized Service Plan for Resident #1 was updated b the Resident Care Director with the resident to include a detailed written description of the type of assistance and actual tasks to be completed by the staff in the ADL of Dressing. The Resident Care Director will provide education to certified staff member on completing ISPs to describe actions and/or interventions in enough detail so that any caregiver that may be unfamiliar with the resident would be able to assist them appropriately based on the ISP. Resident Care Director will update the ISP on residents to reflect any changes during reviews and will ensure all new admission ISPs are individualized and specific to the tasks that are necessary to meet the needs of the resident. [sic]