VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT HAMPTON
1030 TOPPING LANE
Hampton, VA 23666
(757) 826-3728

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: June 5, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted by the Licensing Inspector from the Eastern Region Office on 06/05/2019 from 10:40 AM to 2:43 PM. The complaint alleged concerns with staffing and resident care and related services. There were 88 residents in care at the time of the inspection. A tour of the special care units was conducted, and interviews were conducted with staff. 2 resident records, staff schedules, and time sheets were reviewed. The facility received violations "under" Staffing and Supervision and Resident Care and Related Services. Based on the information reviewed during this inspection a portion of the complaint was found to be valid. The Administrator was not present during the inspection, therefore the areas of noncompliance were discussed with the Assistant Administrator throughout the inspection and during the exit interview. The following was discussed with the Assistant Administrator: staff coverage during breaks, schedules, and physician's orders. Please complete the -Plan of Correction- for each violation cited on the violation notice and return it to me within 10 calendar days from today, 07-13-2019. You will need to specify how the violation will be or has been corrected. Just writing the word corrected is not acceptable. Your plan of correction must include: 1. steps to correct the noncompliance 2. measures to prevent reoccurrences 3. person(s) responsible for implementing and monitoring each step of the corrective measures and / or the preventative measure.

Violations:

Standard #:	22VAC40-73-280-B
Complaint related:	No
Description:	Based on record review and interview, the assisted living facility failed to have staff sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident to ensure compliance with this chapter. Evidence: 1. Staff #2 provided a copy of the ?Staff Care Assignment? written work schedules and the "Timecard Editor" staff time sheets of all staff that were scheduled to work during the 10:45 PM to 7:15 AM shifts for the following dates: a. On 05-16-2019, the total number of residents on the Assisted Living unit (ALU) was 48 residents. The total number of residents on the special care units (SCU) was 13 residents on the men's unit and 28 residents on the women's unit. The minimum required staffing was 2 direct care staff on the men's unit and 3 direct care staff on the women's unit. The written work schedule dated 05-16-2019 documented 7 direct care staff were scheduled to work during the 10:45 PM to 7:15 AM shift. The ?Timecard Editor? dated 05-17-2019 (for 05-16-2019) documented 7 direct care staff worked the 10:45 PM to 7:15 AM shift (staff #3, #4, #6, #7, #8, #9, and #10); however, upon further review of the ?Timecard Editor? 2 of the 7 staff were on break at the same time (staff #3 from 3:13 AM to 3:38 AM and staff #4 from 3:12 AM to 3:56 AM) leaving 5 direct care staff on duty in the SCU and ALU. b. On 05-18-2019, the total number of residents on the ALU was 48 residents. The total number of residents on the SCU was 13 residents on the men's unit and 28 residents on the women's unit. The minimum required staffing was 2 direct care staff on the men's unit and 3 direct care staff on the women's unit. The staff working schedule dated 05-18-2019 documented 9 direct care staff were scheduled to work the 10:45 PM to 7:15 AM shift; however, staff #11 did not work this shift. The "Timecard Editor" dated 05-19-2019 (for 05-18-2019) documented 7 direct care staff worked the 10:45 PM to 7:15 AM shift (staff #3, #5, #7, #9, #13, #14, #15, and #16); however, upon further review of the "Timecard Editor", 3 of the 8 staff were on break at the same time (staff #3 from 3:47 AM to 4:15 AM, and staff #9 from 4:04 AM to 4:15 AM, and staff #13 from 4:02 AM to 4:42 AM) leaving 5 direct care staff on duty in the SCU and ALU. 2. During interview, staff #1 stated the facility pulled the ALU staff to cover on the SCU during the aforementioned breaks, leaving the ALU without staff. Staff #1and staff #2 acknowledged the facility did not have staff sufficient in numbers when the aforementioned staff was on break.
Plan of Correction:	What Has Been Done to Correct? Breaks have been assigned. Staffing numbers monitored to stay in compliance with regulation How Will Recurrence Be Prevented? Associates were spoken to on the importance of following break schedule to remain in compliance with staffing needs. Staff breaks are assigned, issued, and monitored by shift supervisor. Timecard editor monitored for accuracy Person Responsible: RCD, ARCD, shift supervisor, and or designee
Standard #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on record review and interview, the facility failed to maintain a written work schedule, to include any absences on the schedule. Evidence: 1. Staff #2 provided a copy of the ?Staff Care Assignment? written work schedule dated 05-18-2019. The schedule documented staff #12 was scheduled to work during the ?Eve shift? and staff #11 was scheduled to work during the ?Noc shift;? (10:45 PM-7:15 AM) however, the ?Timecard Editor? timesheets revealed both staff did not work on 05-18-2019. 2. During interview, staff #1 confirmed the written work schedule dated 05-18-2019 was not updated to reflect staff #12 or staff #11?s absences.
Plan of Correction:	What Has Been Done to Correct? Communication has been made with the RCD, ARCD, and or designee to have oversight and responsibility of this task How Will Recurrence Be Prevented? RCD will set up binder and maintain daily schedule with all changes and substitutions. We will review in daily stand-up Person Responsible: RCD, ARCD, and or Designee
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's or other prescriber's 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. During resident #1?s record review, a physician?s order on file dated 02-21-2019 documented ?Please discontinue risperidone? however, the February 2019 Medication Administration Record was initialed by staff documenting the Risperidone .25mg tablet was administered to resident #1 for 4 additional days on 02-22-2019, 02-23-2019, 02-24-2019; and 02-25-2019. 2. During interview, staff #1 confirmed the facility received the discontinued Risperidone .25mg order on 02-21-2019, and acknowledged the facility administered the Risperidone .25mg tablet to resident #1 after 02-21-2019.
Plan of Correction:	What Has Been Done to Correct? Medication was removed from cart. MAR reflects current physician/prescribers? orders How Will Recurrence Be Prevented? Medication Observation Pass will be conducted randomly each shift monthly to assure regulatory compliance is met. Order will be reflected on MAR. Person Responsible: RCD, ARCD, and or designee