VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Town Creek Assisted Living Facility
393 Front Street
Lovingston, VA 22949
(434) 263-4313

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: April 2, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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. 22VAC40-80 SANCTIONS.

Comments:

The LI for Town Creek Assisted Living conducted an unannounced monitoring visit at the facility on 4/2/19 from 9am until 4pm under the supervision of the LA and a home office consultant and 11 residents were noted to be in care. A tour of the facility physical plant was conducted and the morning medication pass and mid day meal were observed. Interviews were conducted with residents and staff. Resident and staff records as well as other forms of facility documentation were reviewed. Please respond back to your LI with a plan of correction within 10 days of receipt of this notice. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based on observations, the facility failed to implement their infection control program in regards to CDC guidelines for assisted blood glucose monitoring. EVIDENCE: 1. The glucometers in the meter bags for residents 1, 2 and 7 were not labeled with the residents names on the day of inspection. 2. An unlabeled glucometer was noted on the medication cart at the time of the inspection. Staff person 1 indicated that it is a extra facility meter for use as needed. The LI asked staff person 1 about proper cleaning for the extra meter when in use. Staff person 1 expressed that they would use an alcohol prep pad to wipe the meter off. The LI asked if this cleaning process is consistent with the manufacturers cleaning guidelines. Staff person 1 was not aware of any manufacturers cleaning instructions and the LI noted that the instructions were not with the meter.
Plan of Correction:	The Clinical Coordinator ensured all B/G meters were properly labeled on 4/2/19 and removed back up meter from the medication cart for storage in a separate area on 4/2/19. Clinical Coordinator provided written instructions for all Medication Aides via email on 4/3/19 on how to clean each type of meter and ensured that all meters are cleaned. Clinical Coordinator will provide ongoing training and oversight to all RMAs on meter cleaning process.
Standard #:	22VAC40-73-200-B
Description:	Based on resident and staff record reviews and staff interviews, the facility failed to ensure that direct care staff who are responsible for caring for residents with special health care needs shall only provide services within the scope of their practice and training. EVIDENCE: 1. The LI noted in the record for resident 2 a discharge summary dated 3/21/19 indicating the resident has a diagnosis of Atonic neurogenic bladder with urinary retention and needs to self-catheter. A instruction sheet hanging on resident 2's bathroom door indicates that staff are to assist resident 2 with this procedure by ensure that he properly cleanses himself prior to the procedure and open the catheter and pour a few drops of saline into the catheter. Staff are to hold the orange end of the catheter inside a urinal for collection of urine and that staff may assist resident 2 with catheter removal to avoid spraying of urine. The LI discussed this process with staff person 5 to ensure that direct care staff who are assisting with this procedure have had training on assistance with self-catheterizations including signs and symptoms of complications with this procedure. Staff person 5 expressed that no special training has been conducted. The LI also discussed with staff person 5 that the removal of a catheter from resident 2's 2 body can only can only be assisted by a licensed health care professional.
Plan of Correction:	The Administrator scheduled in-service training which was provided to all Medication Aides on 4/24/19 by a licensed health care professional (RN) which reviewed methods and limitations for RMAs providing assistance for residents who are able to self-catheterize, as well as signs and symptoms of complications related to catheterization issues and overall training on UTIs and bladder anatomy.
Standard #:	22VAC40-73-250-C
Description:	Based on staff record reviews, the facility failed to ensure that all personal and social data was maintained for staff. EVIDENCE: 1. The record for staff 4, hired on 2/4/2019, does not contain the results of a criminal background check.
Plan of Correction:	The Administrator secured the background check at the facility for Staff 4. Administrator also clarified expectations for background check procedures for staff records for Human Resources staff to ensure the Facility remains in compliance with all staff records by having actual background checks maintained at the facility immediately after completion for all newly hired staff after date of inspection.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record reviews, the facility failed to ensure that all required personal and social information was obtained. EVIDENCE: 1. The personal and social information form in the record for resident 2 was incomplete as it was missing the residents known allergies, hobbies, lifetime vocation and birthplace. 2. The personal and social information form in the record for resident 6 was incomplete as it was missing the residents physician, dentist, LDSS and other agency, if applicable; MH/MI/ID history; SA history, if applicable; and current behavioral and social functioning to include strengths and problems.
Plan of Correction:	On 4/19/19, the Administrator discontinued use of prior personal social data form and began using DSS Model Form for personal social data to ensure all needed information is captured.
Standard #:	22VAC40-73-390-A
Description:	Based on resident record review, the facility failed to ensure that a written agreement with all required information was provided to residents prior to admission. EVIDENCE: 1. The written resident agreement in the records for residents 1 through 6 did not contain all required information per this standards requirements.
Plan of Correction:	The Administrator made appropriate updates to the Resident Agreement per needs noted during exit interview to include all information required within the body of the written document, rather than as addendums within the admission packet on 4/24/19.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record reviews, the facility failed to ensure that uniform assessment instruments (UAIs) were completed prior to admission. EVIDENCE: 1. The UAI's in the records for resident 2, 4 and 6 were noted to be incomplete as they did not have the dates that the UAI's were completed.
Plan of Correction:	On 4/4/19, the Administrator communicated with primary referral source to ensure that all UAIs will contain consistent and accurate assessment information as well as being dated accurately. Administrator will ensure that all future referral sources provide accurately completed and dated UAIs prior to acceptance.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure that all identified needs were address on comprehensive individualized plans (ISPs). EVIDENCE: 1. Per Sex Offender screening and resident record, resident 4 is a sex offender; however, this is not addressed on the resident?s comprehensive ISP dated 1/24/2019. 2. The UAI for resident 5 dated 2/5/2019, shows the resident requires supervision via prompts with bathing; however, the ISP does not address the need for verbal prompting. Interview with the AIT confirmed the UAI is an accurate assessment and the resident does require verbal prompting. 3. The record for resident 1 has a physician order dated 3/7/19 for a consistent carbohydrate, diabetic, soft food diet. The comprehensive ISP dated 2/21/19 has that the resident is on a low sugar diet. 4. The record for resident 3, admitted to the facility on 2/12/19 has a preliminary ISP dated 2/12/19 in the record. A comprehensive ISP, completed within 30 days after admission was not present on the day of inspection.
Plan of Correction:	On 4/5/19 the Administrator reviewed inspection findings with Healthcare Oversight Provider and received additional guidance on ISP development. The Administrator met with admissions team and ISP staff to ensure updates were made to all ISPs noted during inspection and to provide supervision around related issues on ISPs moving forward.
Standard #:	22VAC40-73-610-D
Description:	Based on observations and resident record reviews, the facility failed to ensure that a special diet prescribed for a resident by his physician or other prescriber, was prepared and served according to the physician's or other prescriber's orders. EVIDENCE: 1. The record for resident 1 has a physician order dated 3/7/19 for a consistent carbohydrate, diabetic, soft food diet. The LI observed that the facility kitchen is preparing a no concentrated sweet, heart healthy diabetic diet.
Plan of Correction:	Via verbal discussions, and email on 4/19, the Administrator clarified expectations with both Clinical Coordinator and Dietary Coordinator that the diet served for Resident 1 should be following physician?s order given to Facility on 3/7/19.
Standard #:	22VAC40-73-640-A
Description:	Based on observations, the facility failed to implement their medication management plan. EVIDENCE: 1. The LI noted that the facility refrigerator used to store medications contained several vials of Haldol Injectable medication. Manufacturers instructions on the medication box indicate " Do not store medication in refrigerator". 2. A open Lantus and Humalog insulin pen were noted in the medication refrigerator for resident 2. The pens did not contain the date they were opened to ensure they are disposed of within 28 days of opening per manufacturers instructions. 3. A open Lantus and Humalog insulin pen and a Humalog insulin vial were noted in the medication refrigerator for resident 1. The pens and vial did not contain the date they were opened to ensure they are disposed of within 28 days of opening per manufacturers instructions. 4. Two Novolog insulin pens were noted in the medication refrigerator for resident 1. The LI noted that this medication was not listed on the residents April 2019 medication administration record (MAR). Staff person 1 expressed in an interview that the medication had been discontinued but it had not been removed/disposed of from the refrigerator.
Plan of Correction:	On 4/3/19 and 4/4/19, the Clinical Coordinator provided education for all RMAs regarding proper storage and disposal of injectable medications. The Administrator ensured that all medications will be stored in proper location. The Clinical Coordinator ensured undated pens were disposed of and provided education and training for all RMAs on best practices for proper dating, initialing and timely disposal of insulin pens by RMAs.
Standard #:	22VAC40-73-680-D
Description:	Based on observations and resident record review, the facility failed to administer medications in accordance with physician instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1. The LI observed staff person 1 administer a Humalog insulin injection to resident 1 at 11:40am on the day of inspection. THe LI observed that staff person 1 did not use an alcohol swab/pad to clean the injection site prior to administration. Page 278 of The Commonwealth of Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides has listed under General guidelines for administration of subcutaneous injections (B- #7)to cleanse the injection site with an alcohol swab before administration of the injection. 2. The LI observed staff person completed an assisted blood glucose monitoring from resident 2 at approximately 11:45am on the day of inspection. The blood glucose result was 265 which would have required that the resident receive 3 units of Humalog insulin per sliding scale orders. Staff person 1 entered the residents blood glucose result as 235 in the facility electronic medication administration record (EMAR) system which gave instructions to only give 2 units of Humalog insulin. The LI stopped staff person 1 after the incorrect amount of Humalog insulin had been prepared to ensure that the wrong dose was not administered.
Plan of Correction:	The Administrator and Clinical Coordinator will conduct unannounced monitoring of all med pass steps including B/G checks and insulin administration at least monthly on each RMA. Any concerns noted on monitoring checks will be addressed with additional training and refresher courses with identified RMAs if necessary.
Standard #:	22VAC40-73-680-G
Description:	Based on observations, the facility failed to ensure that all over the counter medications were labeled with residents names. EVIDENCE: 1. Two tubes of Insta-Glucose, one which was open, was noted to be unlabeled on the medication cart. 2. An unlabeled tube of Triple Antibiotic Ointment was noted on the medication cart.
Plan of Correction:	On 4/2/19, the Administrator ensured Clinical Coordinator removed unlabeled Insta-Glucose from the cart and moved Triple Antibiotic Ointment to wound care supply kit.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record reviews, the facility failed to ensure that al required information was documented on medication administration records (MAR). EVIDENCE: 1. The March 2019 MAR for resident 2 has staff person 1's initials present on 3/11/19 for the administration of Invega Sustenna intramuscularly. This staff person is an RMA and is unable to administer this medication. In an interview with staff person 1 is was expressed staff person 1 had not administered that medication and that resident 2 goes to a local clinic to receive the medication. 2. The March 2019 MAR for resident 5 has staff person 1's initials present on 3/14/19 for the administration of Haloperidol Dec intramuscularly. This staff person is an RMA and is unable to administer this medication. In an interview with staff person 1 is was expressed staff person 1 had not administered that medication and that resident 5 goes to a local clinic to receive the medication.
Plan of Correction:	The Administrator communicated with Pharmacy administrative staff on 4/3/19 to create an exception in online eMAR system to allow documentation to reflect off site administration of injectable medication at local MH clinic. This feature allows Facility RMA staff to document proper time and location of administration of medication in eMAR system, remaining in compliance. Clinical Coordinator provided followup education and guidance for all RMAs on using exceptions in eMAR to properly document offsite injectables.