VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Lady of Perpetual Help Health Center
4560 Princess Anne Road
Va beach, VA 23462
(757) 495-4211

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: April 23, 2019 and April 24, 2019

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 The Criminal History Record Report

Comments:

This was an unannounced annual monitoring inspection conducted by two Licensing Inspectors from the Eastern Regional Office. The inspection was conducted on April 23, 2019 from 9:06 AM until 4:55 PM and on April 24, 2019 from 9:14 AM until 4:02 PM. There were 86 residents in care. During the inspection a tour of the building and grounds was conducted, breakfast and lunch were observed as posted on the menu. A medication pass observation was conducted and medication carts inspected in the Christopher Center and in the Extensive Assisted Living (EAL). Resident and staff records were reviewed to include a review of criminal background checks for all new staff hired since the previous inspection. Resident and family interviews were conducted. The following was discussed with the Administrator and staff throughout the inspection and during the exit interview: Ensuring the health care oversight and dietician's report date reflects the date, month, and year; Residents Rights- content to align with the Rights and Responsibilities for Residents in Assisted Living Facilities per Code of VA; Discussed new process for ISP training for staff; Activities calendar to reflect the required hours of scheduled activities as well as changes and substitutions made; Staffing in the memory care unit. The facility received violations in the areas of Personnel, Admission, Retention & Discharge of Residents, Resident Care and Related Services, Emergency Preparedness. 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. Your plan of correction should include: 1. Step(s) to correct the non-compliance with the standard(s) 2. Methods to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative action. If you have any questions please contact your inspector, Reyna Rios at 757-353-0430.

Violations:

Standard #:	22VAC40-73-1120-B
Description:	Based on record review and interview, the facility failed to ensure the activities calendar reflect that there were at least 21 hours of scheduled activities available to the residents each week. Evidence: 1. On 04-24-2019, during review of the scheduled activities for the ?Christopher Center? memory care unit, the Licensing Inspector observed the following: a. The February 2019 activity calendar revealed 18.5 hours of activities were scheduled on 02-03-2019 through 02-09-2019; 20 hours of activities were scheduled on 02-10-2019 through 02-16-2019; 19.5 hours of activities on 02-17-2019 through 02-23-2019; and 18 hours of activities on 02-24-2019 through 03-02-19. b. The March 2019 activity calendar revealed 18 hours of activities were scheduled on 03-03-2019 through 03-09-2019; 19.5 hours of activities were scheduled on 03-10-2019 through 03-16-2019; 18.5 hours of activities on 03-17-2019 through 03-23-2019; and 20 hours of activities on 03-24-2019 through 03-30-19. c. The April 2019 activity calendar revealed 17.5 hours of activities were scheduled on 03-31-2019 through 04-13-2019, and 17 hours of activities were scheduled on 04-14-2019 through 04-20-2019. 2. During interview on 04-24-2019, staff #5 acknowledged the February, March, and April 2019 activity calendars for the Christopher Center did not reflect 21 hours of scheduled activities.
Plan of Correction:	1) The facility has maintained a minimum of 21 hours of activities available to the residents in the memory care, each week. There was inadequate evidence due to not listing the entire length of an activity, i.e. 2 hours for a scheduled movie. 2) The posted schedule will now include the length of time for each activity scheduled, for any activity lasting longer than 30 minutes. 3) Director of Life Enrichment or designee to monitor for compliance.
Standard #:	22VAC40-73-1130-A
Description:	Based on record review and interview, the facility failed to ensure when 20 or fewer residents are present, at least two direct care staff members should be awake and on duty at all times in each special care unit who should be responsible for the care and supervision of the residents. For every additional 10 residents, or portion thereof, at least one more direct care staff member should be awake and on duty in the unit. Evidence: 1. On 04-24-2019, during review of the facility?s staff written work schedules ?Christopher Center Daily Schedule? with staff #1, the Licensing Inspector (LI) observed the following: a. The facility has three separate special care locked units (Rose Pavilion, Lily Pavilion, and Iris Pavilion). b. On 03-02-2019, the census for the Iris Pavilion was 21 residents, the Lily Pavilion was 18 residents, and the Rose Pavilion was 20 residents. The ?Christopher Center Daily Schedule? revealed 2 direct care staff per Pavilion were scheduled to work during the 11:00 PM to 7:00 AM shift. However, the minimum required staffing on the Iris Pavilion was 3 direct care staff, 2 direct staff on the Lily Pavilion, and 2 direct care staff on the Rose Pavilion. c. On 04-13-2019, the census for the Iris Pavilion was 20 residents, the Lily Pavilion was 18 residents, and the Rose Pavilion was 21 residents. The ?Christopher Center Daily Schedule? revealed 2 direct care staff per Pavilion were scheduled to work during the 11:00 PM to 7:00 AM shift. However, the minimum required staffing on the Iris Pavilion was 2 direct care staff, 2 direct staff on the Lily Pavilion, and 3 direct care staff on the Rose Pavilion. 2. During interview on 04-24-2019, LI asked staff #1 if the aforementioned information was correct. Staff #1 confirmed there were only 2 direct care staff that worked on each Pavilion during the 11:00 PM to 7:00 AM shift on 03-02-2019 and 04-13-2019. Staff #1 indicated that the staffing was based on the total census for the special care units combined and not based on the individual Pavilions.
Plan of Correction:	The facility has requested a desk review.
Standard #:	22VAC40-73-210-G
Description:	Based on record review and interview, the facility failed to ensure direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training. Documentation of the type of training received, the entity that provided the training, number of hours of training, and dates of the training should be kept by the facility in a manner that allows for identification by individual staff person and is considered part of the staff member's record. Evidence: 1. On 04-24-2019, during staff #10 record review, staff #10 was hired on 11-27-2007. Staff #12 provided the Licensing Inspector (LI) with staff #10?s annual training hours from 11-27-2017 through 11-27-2018; which totaled 7.5 hours. Staff #12 was unable to provide LI with additional training hours for staff #10. 2. During interview, staff #12 acknowledged staff #10 did not have the required hours of annual training.
Plan of Correction:	1) On 12/23/2018, Staff #10 completed the remaining 6.75 hours of her scheduled training hours. 2) Department Managers will monitor the Relias Training compliance report, weekly, to ensure assigned trainings are being completed prior to the end of the month that the trainings are assigned in. 3) Administrator or designee to monitor for compliance.
Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview, the facility failed to ensure each direct care staff member maintained 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, and that each direct care staff member who does not have current certification in first aid, receive certification in first aid within 60 days of employment. Evidence: 1. On 04-24-2019, during review of staff #8's record, staff #8 was hired on 01-14-2019 as a CNA. Staff #8's record did not contain documentation of First Aid certification obtained prior to employment or within 60 days of hire. 2. Interview with staff #1 was unable to locate First Aid certification in the staff's record and acknowledged staff #8 did not obtain a First Aid certification within 60 days of hire. 3. During staff #10?s record review, Licensing Inspector (LI) observed staff #10 is a CNA/RMA. The First Aid certification in the record for staff #10 had an expiration date of 09-2018. Staff #6 provided LI with an updated First Aid certification dated 02-05-2019 which was obtained through EMS Safety. Staff #6 was unable to provide an additional First Aid certification for staff #10 from one of the approved organizations. 4. During interview on 04-24-2019, staff #1and staff #6 acknowledged staff #10?s First Aid certificate was not obtained from one of the approved organizations. In addition, staff #1 and staff #6 acknowledged staff #10 was not certified in First Aid from 09-2018 through 02-04-2019.
Plan of Correction:	1) On 5/16/2019, Staff #8 and Staff #10 completed a First Aid Training course, provided through the American Heart Association. 2) A 100% audit will be conducted to determine that each direct care staff member has a current First Aid certification, through an approved organization. All new hires who do not present a current First Aid card, through an approved organization will be scheduled to attend a course, offered at our community by our staff CPR / First Aid Instructor, certified through the American Heart Association within the first 60 days of employment. 3) Director of Nursing, Director of Resident Services or designee to monitor for compliance.
Standard #:	22VAC40-73-320-B
Description:	Based on record review and interview, the facility failed to obtain a risk assessment for tuberculosis annually on each resident 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 review of resident records, the facility was unable to provide documentation that the following TB screenings were completed annually: a. Resident #4: The most current TB screening form was dated 02-01-2019. The form was checked "none" under "TB symptoms" but was not signed or dated by a qualified health professional. b. Resident #5: The most current TB screening form was dated 03-07-2018, on the date of resident's admission. The resident did not have an annual TB screening in the record at the time of inspection. c. Resident #7: The most current TB screening on file dated 02-07-2019 was left blank, and did not indicate if the resident was free of any TB symptoms. 4. During interview, staff #4 stated that an LPN completed the TB screening for resident #4 but failed to sign it. Staff #4 acknowledged resident #4 and #5 did not have a current completed annual TB screening on file. 5. During a separate interview, staff #3 acknowledged the annual TB screening for resident #7 was left blank.
Plan of Correction:	1) The Risk Assessments for Tuberculosis / Tuberculosis screening forms were completed for Residents #4, #5 and #7 on 4/24/19. 2) A 100% audit will be performed to ensure each resident has an annual Risk Assessment for Tuberculosis completed. A schedule will be developed, to reflect the due dates of the annual screenings, schedules will be monitored monthly to ensure compliance is achieved. 3) Director of Nursing, Director of Resident Services or designee to monitor for compliance.
Standard #:	22VAC40-73-450-A
Description:	Based on record review and interview, the facility failed to ensure on or within seven days prior to the day of admission a preliminary plan of care was developed to address the basic needs of the resident that adequately protects the resident?s health, safety, and welfare. Evidence: 1. During resident #8?s record review on 04-23-2019, the resident admitted to the facility on 08-03-2018. The preliminary Individualized Plan of Care (ISP) was dated 09-11-2018, and the comprehensive ISP was dated 12-04-2018. 2. During interview, staff #3 acknowledged resident #8?s preliminary ISP was not developed on or within seven days prior to the resident admitting to the facility.
Plan of Correction:	1) The ISP for resident #8 was reviewed for completion and accuracy. 2) A 100% audit will be performed to assess for the completion of ISP?s, within the required timeframes. An ongoing audit of ISP?s, on the date of a resident?s admission, will be performed to ensure timely completion of the preliminary ISP occurs on or within seven days prior to the day of admission. 3) The Director of Nursing, Director of Resident Services or designee to monitor for compliance.
Standard #:	22VAC40-73-450-D
Description:	Based on record review and interview, the facility failed to ensure when hospice care is provided to a resident, the services provided by the hospice organization are included on the individualized service plan (ISP). Evidence: 1. During review of resident #3's record, the ISP dated 01-11-2019 indicated the resident was on hospice. The ISP indicated the resident receives a weekly social worker visit, a pastoral counselor weekly, an RN/LPN two times per week, and a CNA two times per week. The services provided by the social worker, pastoral counselor, the RN/LPN and CNA were not listed on the ISP. 2. During interview, staff #4 acknowledged the resident was on hospice services and that the ISP did not include the service provided by each discipline mentioned.
Plan of Correction:	1) The Individualized Service Plan for resident #3 was updated. 2) The Unit Managers will audit the Individualized Service Plans for those residents receiving hospice services, to ensure the inclusion of services that each discipline will be providing, is listed on the ISP. Hospice providers will be asked to develop their plan of care to show the specific services each discipline will provide, to add to the community ISP. 3) The Director of Nursing, Director of Resident Services or designee to monitor for compliance.
Standard #:	22VAC40-73-520-I
Description:	Based on observation, record review, and interview, the facility failed to ensure if one activity is substituted for another, the change should be noted on the schedule. Evidence: 1. On 04-23-2019, during the morning activity, the Licensing Inspector (LI) observed the activity calendar posted outside of the dining room area. The posted activity at 9:45 AM was Poetry in Motion, and the 10:00 AM activity was Ladder Ball. The calendar revealed both of the activities were scheduled to be conducted in the living room area (LR2). 2. On 04-23-2019 at 9:48 AM, LI observed staff #14 reviewing a ?Top of the Morning? flyer to the residents in the living room area (LR2). LI did not observe the scheduled 9:45 AM activity ?Poetry in Motion.? 3. During interview on 04-23-2019, staff #14 and staff #15 indicated that the Poetry in Motion and Ladder Ball activity would be conducted at a later time; and acknowledged the posted activity calendar was not updated to reflect the ?Top of the Morning? flyer being conducted at 9:45 AM instead of Poetry in Motion.
Plan of Correction:	1) The posted activity schedule was updated to reflect the activities that did occur and the time in which they occurred, on 4/24/19. 2) The posted schedule will be kept up-to-date, with manual entries to reflect any changes that occur. The schedule will also be adjusted to allow for more flexibility in the scheduled times of certain activities as is often needed if an activity may run a little longer, due to resident response / involvement. 3) Director of Life Enrichment or designee to monitor for compliance.
Standard #:	22VAC40-73-660-B
Description:	Based on observation, record review, and interview, the facility failed to ensure a resident may keep their own medication in an out-of-sight place in their room if the Uniform Assessment Instrument (UAI) has indicated that the resident is capable of self-administering medication. The medication and any dietary supplements shall be stored so that they are not accessible to other residents. Evidence: 1. During a tour of the Extensive Assisted Living (EAL) with staff #3 Licensing Inspector (LI) observed two bottles of Ammonium Lactate 12% lotion on resident #1's bathroom sink. During the tour staff #3 stated the facility staff administers the lotion to resident #1. a. During review of resident #1's record, the resident had an order dated 03-01-2019 to apply Ammonium Lactate topically to feet and legs two times per day. The order did not indicate the resident could self-administer or keep at bedside. b. Review of resident #1's Uniform Assessment Instrument (UAI) dated 02-12-2019 revealed the resident needs assistance with medication administration by an RMA/LPN and did not indicate the resident is capable to self-administer medications. 2. Also during the tour of the EAL with staff #3, the LI observed Nystatin cream and Calmoseptine Ointment located on top of resident #7?s bathroom vanity. a. During resident #7?s record review on 04-23-2019, the current UAI dated 02-04-2019 indicated the resident needs assistance with medication administration, to be administered by an RMA/LPN. The resident had an order for the Nystatin Cream dated 01-22-2019; however, the order did not indicate the resident was able to self-administer medications. In addition, the resident did not have an order on file for the Calmoseptine ointment or any additional orders on file to indicate the resident could self-administer medications. 3. During interview on 04-23-2019, staff #3 acknowledged resident #7 was not permitted to keep medications in his room.
Plan of Correction:	1) * The Ammonium Lactate topical lotion was removed from resident #1?s bathroom sink and the Nystatin Cream & the Calmoseptine Ointment were removed from resident #7?s bathroom vanity on 4/23/2019. ? Room rounds were performed in each of the resident rooms on the unit to ensure no other room had items at the bedside or in the bathrooms, on 4/23/19. 2) * Physician orders were obtained for those residents who have lotions, creams or ointments that are to be applied by direct care staff , to be kept at bedside, in an out of sight location. ? Room audits will continue weekly x4, then monthly x3 at various times of the day to ensure compliance is achieved. Ongoing room rounds will occur, randomly to assess for continued compliance. 3) Director of Nursing or designee to monitor for compliance.
Standard #:	22VAC40-73-950-C
Description:	Based on record review and interview, the facility failed to complete a semi-annual review on the emergency preparedness and response plan for residents. The review should be documented by signing and dating. Evidence: 1. During review of the emergency preparedness and response plan semi-annual review with staff #5, it was discovered that the facility did not have documentation of a having completed a review of the emergency preparedness and response plan with residents in the Extensive Assisted Living (EAL). 2. During interview staff #5 acknowledged the facility did not have documentation of a review completed with the residents in the EAL.
Plan of Correction:	1) The emergency preparedness review was held again with the EAL residents to ensure signatures were received from all that could sign and written acknowledgment of attendance was noted on those who could not sign on 4/30/19. 2) Along with the Emergency Preparedness review that is sent out to each family member every 6 months, a review is held with the residents. We will obtain a signature, from all who are capable of signing, at the time of this review. For those who are unable to sign, we will ensure a note is made to capture all who were in attendance, at the time of the review. 3) Director of Life Enrichment or designee to monitor for compliance.