VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living Communities
201 & 202 Lillian Lane
Lynchburg, VA 24502
(434) 385-5102

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 30, 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:

On 5/30/2019 two inspectors conducted a renewal study (8:40am to 4:50pm). 93 residents were in care, with 42 of those in the special care (memory care) unit. 10 resident records and five staff records were fully reviewed, and other records were partially reviewed. All new staff records not having a full review were checked for compliance with background check regulations. Medication passes were observed in both buildings. A physical plant tour was done, meals and activities were observed, staff and residents were interviewed. Medication carts were checked. The management staff and LIs discussed the following regulations: 22 VAC 40-73-380-A, 450-E, 560-A, and 325-B. Some emergency reviews for residents are due prior to 6-19-2019. Some of the comprehensive service plans completed by the prior licensee must be updated.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on documentation review, the facility failed to have an assessment showing that a resident has a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. EVIDENCE: 1. Resident 10 lives in memory care unit (safe, secure unit). The Assessment of Serious Cognitive Impairment for resident 10 shows the resident does not have a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. According to the documentation, resident 10 does not belong in safe, secure unit.
Plan of Correction:	This resident?s physician did not complete the paperwork correctly when the resident was being discharged from another assisted living due to cognitive impairment. The error on the physician?s paperwork was not caught prior to admission. This resident was reassessed on 5/30/19 and has the appropriate paperwork in his chart. The Executive Director reviewed what is required on these memory care admission forms with the Resident Care Director and the Marketing Director and they will monitor to ensure all admission paperwork is completed correctly. In the future, should the physician not complete the paperwork correctly for a memory care admission, the facility will work to correct the paperwork prior to admission and if that can?t be done prior to the planned admission day, delay the admission until they physician does provide correct paperwork.
Standard #:	22VAC40-73-100-C-1
Description:	Based on observation, the facility failed to implement a required section of the infection control plan. EVIDENCE: 1. A medication cart in the memory care building was discovered to have an unlabeled glucometer. This was found by by the LI and staff 1.
Plan of Correction:	This glucometer belonged to a resident who was recently discharged from the facility and the label was removed but the glucometer had not yet been removed from the cart. Glucometer was removed on day of inspection.
Standard #:	22VAC40-73-250-C
Description:	Based on review of staff files, the facility failed to show that a person hired as a direct care aide is qualified to do this job. EVIDENCE: 1. The file for staff 5, hired on 4/1/2019 as a nursing assistant (direct care aide), lacks documentation to support that staff 5 is qualified to do this type of work.
Plan of Correction:	The certification for staff 5 had been reviewed prior to hire, but not yet filed in the chart. The Business Office Manager will ensure these items are filed in the personnel chart prior to staff starting on the schedule.
Standard #:	22VAC40-73-270-1
Description:	Based on staff record review, the facility failed ensure that a staff person had training on methods of dealing with agitated and aggressive residents prior to being involved in the care of such residents. EVIDENCE: 1. The file for staff 6, hired on either 3/18/2019 or 3/20/2019, shows that this person works in both buildings at the facility. The memory care building has agitated or aggressive residents. There is no documentation to support that staff 6 had this training until 4/9/2019.
Plan of Correction:	This is the LPN hired for second shift as a supervisor and she worked learning all administrative tasks up until that date, not working directly with memory care residents until after she had the training on 4/9/19. Otherwise care staff are given aggressive behavior training during their orientation period, prior to their working directly with the residents. Facility will provide this LPN with a train the trainer on the aggressive behavior training so that she and the RCD can both conduct this training with new staff.
Standard #:	22VAC40-73-290-A
Description:	Based on document review, the facility failed to maintain a written work schedule that shows which direct care staff member is in charge at any given time. EVIDENCE: 1. The written schedule does not show is in charge from 7A to 7P on May 30 and 31, June 3 and 4, 2019.
Plan of Correction:	The master schedule had some changes in staff working, and it was when those changes occurred that another staff person in charge was not underlined, however the updated staff person in charge was showing on the daily sheets. While the Resident Care Director and designee will underline a new staff person in charge when changes occur, the Resident Care Director will also add a note to the master schedule ?check the daily sheets? for changes.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to ensure that the direct care staff in charge was posted. EVIDENCE: 1. The memory care building posted the in- charge person, but that person had been off duty as of 2pm the day before the inspection. A staff person is required to be on-site to be shown as in-charge.
Plan of Correction:	The staff person in charge posting was not updated by the Administrative Assistant when the change occurred, as is the process for the facility. Administrative Assistant was reminded to change this out when the staff person in charge changes.
Standard #:	22VAC40-73-310-B
Description:	Based on review of resident records, the facility failed to have a pre-admission face-to-face interview with a prospective resident. EVIDENCE: 1. The record for resident 1, admitted 4/23/2019, lacks documentation to support that a face-to-face pre-admission interview was done.
Plan of Correction:	This was completed by the Resident Care Director, but not filed in the resident record. The RCD will ensure she files the interviews in the record upon completion. The Administrator created an audit tool that matches the regulations and Tabula Pro EMR system and the team is using this going forward.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure than new residents had physical exams within 30 days prior to admission. EVIDENCE: 1. Resident 7 was admitted on 5/20/2019 and the pre-admission physical is dated 2/13/2019. 2. Resident 10 was admitted on 3/30/2019 and the pre-admission physical is dated 2/22/2019.
Plan of Correction:	Both residents had physical exams prior to admission on the date the physicians signed each document, for Resident 7 it was 5/16/19 and for Resident 10 it was 3/29/19. The physician incorrectly put the wrong date at the top of the page where he was to put the date of that day?s physical and not their last physical prior to the most recent physical. The Resident Care Director and Marketing Director will monitor to ensure all admission paperwork is completed correctly.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that uniform assessment instruments (UAI) were completed in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. Resident 1 was admitted on 4/23/2019 and the UAI, due prior to admission, is dated 5/1/2019. The UAI for resident 1, dated 5/1/2019, shows that wheeling is not performed. According to staff interview, this resident does not use a wheelchair, so it should have been assessed as no help needed. 2. The UAI for resident 7 shows that the resident both needs no assistance with wheeling, and that it is not performed. These two assessments are contradictory according to Assessment in Assisted Living Facilities (22VAC30-110). 3. The UAI for resident 8 shows that the resident requires human help with physical assistance when transferring. The C-ISP for resident 8 shows that both mechanical and human help with physical assistance is required. Staff 2 stated that the services on the C-ISP are correct.
Plan of Correction:	The Resident Care Director completed a UAI prior to admission and another the first week of admission as an update but did not save the UAI done prior to admission in the resident record. RCD will ensure she files the initial UAI completed prior to admission. The Administrator created an audit tool that matches the regulations and Tabula Pro EMR system and the team is using this going forward and will audit all charts in Tabula Pro by June 28th, 2019.
Standard #:	22VAC40-73-450-A
Description:	Based on resident record review, the facility failed to complete a preliminary plan of care on or within seven days prior to the day of admission. This plan is required to address the basic needs of the resident and adequately protects his health, safety, and welfare. EVIDENCE: 1. Resident 1 was admitted 4/23/2019 and the preliminary care plan (a.k.a. individualized service plan or ISP), is dated 5/1/2019 Resident 1 is assessed as needing to have lay persons administer medication (registered medication aides), and the ISP, dated 5/1/2019, shows that care assistants are administering medications. Care assistants are not qualified to do this.
Plan of Correction:	Resident Care Director will ensure all ISPs are done within DSS timeframes. Resident Care Director has corrected the ISP so that it reads that RMAs administer medications, and reflects the fact that the community is administering medications using the RMAs and not care staff, as they are doing so correctly. Master ISP was corrected in the Tabula Pro EMR system as well.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to have needs properly addressed on comprehensive individualized service plans (C-ISP). EVIDENCE: 1. The physical exam for resident 8, done 3/26/2019, shows this resident has allergies to levaquin, naprosyn, penicillin, and sulfa, and the C-ISP only addresses the allergy to penicillin. 2. The uniform assessment instrument (UAI) for resident 10 show this resident is assessed as needing mechanical and human help with physical assistance when climbing stairs. This need is not addressed on the C-ISP dated 3/30/2019.
Plan of Correction:	Resident 8 had the additional allergies added. Resident 10 ISP?s need for mechanical and human help with stairclimbing stairs was added. RCD will work to ensure all identifiable needs are on the ISP.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review, the facility failed to include hospice information on comprehensive individualized service plans (C-ISP). EVIDENCE: 1. Resident 10 began hospice services on 4/10/2019, and the facility did not add these services to the C-ISP. The services are listed on a separate document. 2. Resident 4 began hospice services on 11/8/2018 and the services were reviewed on 1/31/2019. The facility did not add the services to the C-ISP. They are on a separate document.
Plan of Correction:	On all inspections since February 2017, DSS required facility to have a separate hospice ISP from the ISP. The facility will start doing a combined hospice and comprehensive ISP which includes hospice, as DSS has instructed on the 5/30/19 inspection.
Standard #:	22VAC40-73-560-E
Description:	Based on observation and staff interviews, the facility failed to keep resident records current. EVIDENCE: 1. During the inspection, staff members were unable to locate all required sections of resident records upon request. Some parts are in notebooks, "to be filed" areas, or in the physical therapy room.
Plan of Correction:	The falls risk ratings were in the physical therapy room and provided during the inspection. Administrator and Resident Care Director have worked with the Tabula Pro Electronic Medical Records provider, so the falls risk ratings are now be a part of the residents EMR in the new falls tracker.
Standard #:	22VAC40-73-680-B
Description:	Based on observation, the facility failed to keep medication in the pharmacy container until administered. EVIDENCE: 1. Loose, unpackaged pills were found by the LI and staff 1 in the medication cart on Dogwood Hall in the memory care unit.
Plan of Correction:	3 ? pills were found on this cart and removed the day of inspection. Memory Care Director and designee do routine medication cart audits routinely. RMAs were reminded they carry out the day to day medication administration and should they be aware of a pill that fell into the cart, remove it and determine which medication this is and to which resident it is for.
Standard #:	22VAC40-73-930-D
Description:	Based on document review, the facility failed to conduct overnight rounds in the memory care (safe, secure) unit for resident unable to use a signaling device (call bell system). EVIDENCE: 1. There is no documentation to support that overnight rounds were done in the memory care unit on 5/24/2019 at 12am, 2am, 4am, 6am and on 5/26/2019 at 8pm or 10pm.
Plan of Correction:	Memory Care Director and designee routinely review the ADL form where this is documented to ensure care staff are recording this. Care Staff were reminded to document their every two hour overnight rounds before leaving at the end of their shift.
Standard #:	22VAC40-73-980-B
Description:	Based on observation, the facility failed to have a complete first aid kit in a vehicle that transports residents. EVIDENCE: 1. The first aid kit in the facility fan has an inoperable thermometer and the hand cleaners are expired.
Plan of Correction:	The hand sanitizer and thermometer were replaced the day of inspection. The Activities Director checks the van for these items and will ensure the first aid kits are incompliance. She was unaware that particular hand sanitizer had an expiration date. It was replaced with hand sanitizer that does not expire.
Standard #:	22VAC40-90-30-B
Description:	Based on review of staff records, the facility failed to ensure that a sworn statement or affirmation (SD) was completed for all applicants for employment. EVIDENCE: 1. Staff 7, hired on 3/25/2019, completed the SD after employment, on 3/26/2019. 2. Staff 8, hired on either 4/12/2019 or 1/17/2019, completed the SD after employment, on 5/2/2019.
Plan of Correction:	The Business Office Manager and Administrative Assistant were reminded the sworn disclosure is to be signed at the hire date, prior to the start date. The BOM will audit all new hire charts, prior to the start date, to ensure this has been done.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to obtain Virginia State Police Criminal History Record reports (CRIM) on or prior to the 30th day of employment for new staff. EVIDENCE: 1. Staff 8 began employment on 4/12/2019 or 4/17/2019, and on 5/30/2019 the CRIM was not in the staff file and could not be located on-line or in papers needing to be filed. 2. Staff 10 began employment on 3/26/2019, and on 5/30/2019 the CRIM was not in the staff file and could not be located on-line or in papers needing to be filed.
Plan of Correction:	The Business Office Manager did not have a copy of staff person 8?s CRIM to show it had been done. The BOM will ensure she makes a copy of all submitted CRIMS to show they have been submitted. The BOM resubmitted staff person?s CRIM on 6/3/19. Staff person 10?s CRIM was done through a third party source and shown to the DSS inspector. DSS does not accept third party sources, and the facility stopped using them in early April 2019.