VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lillian's Loving Care
3736 Turnpike Road
Portsmouth, VA 23701
(757) 393-9241

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 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 22VAC40-90 The Criminal History Record Report

Comments:

This was an unannounced renewal inspection conducted by the Licensing Inspector from the Eastern Regional Office. The inspection was conducted on May 2, 2019 from 10:09 AM until 5:20 PM. There were 28 residents in care. During the inspection a tour of the building and grounds was conducted. A medication pass observation was conducted, as well a check of the medication cart. A lunch meal and a Bingo activity were observed. Resident and staff records were reviewed to include a review of criminal background checks for new staff hired. Resident interviews conducted and a collateral interview. The following was discussed during the inspection: Incident reports to include a 24 hour notification and a 7 day written report; Training information to be included with sign-in sheets, Updating Resident Agreement and Disclosure statement; Staff schedules and posting of the on-site person in charge; Activities calendar to reflect all activity categories on the calendar; Designated smoking areas for residents and non-smoking area for non-smokers. Discussed possible use of front porch, as well as side porch. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction should include: 1. Step(s) to correct the non-compliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person responsible for implementing each step and/or monitoring any preventative action(s). If you have any questions, please contact your inspector Reyna Rios at 757-353-0430.

Violations:

Standard #:	22VAC40-73-100-C-1
Description:	Based on observation and interview, the facility failed ensure staff implement procedures for infection prevention methods to include means to ensure hand hygiene. Evidence: 1. During the 2:00 PM medication pass observation with staff #2, Licensing Inspector observed staff #2 administer medications to residents #4, #7, #8, and #9 without washing hands or sanitizing in between residents. Staff #2 was not wearing gloves. 2. During interview, staff #2 acknowledged hand washing and/or sanitizing did not occur during the medication pass.
Plan of Correction:	The facility will make sure that medication aides implement procedures for infection prevention and making sure to perform proper hand hygiene when administering medication.
Standard #:	22VAC40-73-250-D
Description:	Based on record review and interview, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment should be no older than 30 days. Evidence: 1. During review of staff #3's record, staff #3 was hired on 04-01-2019. The most current TB screening in the record was dated 08-06-2018, which was older than 30 days. 2. During interview, staff #2 acknowledged the facility did not have documentation of a TB screening completed within 30 days and prior to the first day of work for staff #3.
Plan of Correction:	The facility will make sure that each staff have a Tuberculosis (TB) risk assessment within seven days prior or within 30 days prior to the first day of work.
Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. During review of staff records, staff #2 is an RMA/PCA (date of hire 08-21-2014). The most current first aid/CPR certification in the record expired on 4-14-2019. 2. During interview, staff #2 acknowledged that the first aid/CPR certification was expired and that there was no other first aid/CPR certification on file.
Plan of Correction:	The facility will make sure that Direct care staff member will maintain a current certification of first aid from accredited source.
Standard #:	22VAC40-73-290-A
Description:	Based on record review, the facility failed to ensure staff written schedules indicate the name and job classification of the person in charge at any given time. Evidence: 1. Review of the April/May 2019 staff schedule revealed the schedule did not include the name of the person in charge for 04-21-2019 through 05-04-2019. 2. During interview, staff #2 acknowledged the written staff schedule for April/ May 2019 did not indicate the person in charge.
Plan of Correction:	The facility will make sure that staff written schedules will indicate the name and job classification of the person in charge at any given time.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure within the 30 days preceding admission, a person have a physical examination by an independent physician, to include the results of a risk assessment completed within 30 days prior to a resident's admission, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. During record review, resident #2 was admitted on 04-01-2019. The TB screening in the record was dated 04-12-2019, 12 days after the resident's admission. 2. Resident #5 was admitted to the facility on 01-10-2019. The physical examination report indicated the physical exam was completed on 10-26-2018. Further review revealed resident #5's TB screening was dated 10-19-2018. The physical examination and TB screening were not completed within 30 days of the resident's admission. 3. During interview, staff #2 acknowledged the TB screening dates for resident #2 and #5, and the physical exam for resident #5 were not within completed 30 days of the residents' admission.
Plan of Correction:	The facility will make sure to have a physical examination by an independent physician and a result of a risk assessment of tuberculosis (TB) absence are both done within 30 days prior to a resident's admission.
Standard #:	22VAC40-73-350-B
Description:	Based on record review and interview, the facility failed to ascertain, prior to admission, whether a potential resident is a registered sex offender. Evidence: 1. During resident record review, Licensing Inspector found that the sex offender screening was not completed prior to the resident's admission for the following residents: a. Resident #2 was admitted on 04-01-2019. The sex offender screening was completed on 04-03-2019. b. Resident #5 was admitted on 01-10-2019. The sex offender screening was completed 7 days after the resident's admission on 01-17-2019. 2. During interview, staff #2 acknowledged the sex offender screening for resident #2 and #5 were not completed prior to the residents' admission.
Plan of Correction:	The facility will make sure to obtain sex offender record prior to admission to determine whether a potential resident is a sex offender.
Standard #:	22VAC40-73-680-D
Description:	Based on observation, record review and interview, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. Evidence: 1. During the medication pass observation with staff #2, resident #9 requested a PRN Naproxen due to back pain. Staff #2 administered the medication to the resident. The resident took the medication with coffee. 2. During review of the resident's record, the resident had a physician's order dated 02-21-2019 for "Naproxen 500mg 1 tab with food or milk every 12 hours orally PRN". 3. During interview, staff #2 acknowledged the resident's Naproxen 500mg was not administered with food or milk as per the physician's order.
Plan of Correction:	The facility will make sure medications are administer in accordance with the physician's or other prescriber's instructions.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the exterior of the building was free of rubbish. Evidence: 1. On 05-02-2019 upon arrival at the facility at 10:09 AM, Licensing Inspector (LI) observed the facility's side porch leading to the parking area, was blocked off on both sides of the steps. The left side was blocked off with a foldable picnic table across the floor. The right side was blocked off with two walkers, and flower pots. 2. During the tour of the facility with staff #2, LI observed the front porch contained a dresser, a couch, 2 broken red chairs, several lamps and a high back Geri-chair. 3. During interview, staff #2 stated the items on the front porch were garbage and were not in use. Staff #2 also acknowledged the items blocking the side porch.
Plan of Correction:	The facility will make sure that the exterior of the building is free of rubbish.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and interview, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. During review of staff #4's record with staff #2, staff #4's date of hire is 04-01-2019. The criminal history record was requested on 04-15-2019. 2. During interview, staff #2 stated the facility had not received staff #4's criminal history record report on the date of the inspection (05-02-2019), 32 days after the start of staff #4's employment.
Plan of Correction:	The facility will make sure to obtain the criminal history record report on or prior to the 30th day of employment for each employee.