VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Huntington
11143 Warwick Boulevard
Newport news, VA 23601
(757) 223-0888

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: July 8, 2019 and July 9, 2019

Complaint Related: No

Areas Reviewed:

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 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was conducted over the course of two days, 7-8-19 (ar 07:43a/dep 5:31p) and 7-9-19 (ar 1:30p/ dep 5:31p). The facility census on 7-8-19 was 26. A medication pass observation was conducted, activity observed, breakfast meal observed on 7-8-19, emergency protocol reviewed and discussed with administrator, first aid kits reviewed, staff and resident records reviewed, resident council and inspection protocol conducted. The exit interview and violations reviewed with administrator on both days of the inspection. The acknowledgement document signed by the administrator. Comment: The inspector again reminded the administrator of the new regulatory requirements which became effective in 2018. The inspector also reminded the administrator of the keeping the staff employment information for the ALF facility licensed by DSS, clearly distinguished for DSS requirement and not integrated with the nursing facility next door which DSS have no jurisdiction. Administrator and LI discussed glucose protocol and glucometer, residents typically do not share glucometers, each resident typically have their own and all equipment individually labeled per resident. Activity chart should include length of time of each activity and all category per activity standard. Inspection unable to determine staff, volunteers initial review of infection control per 2018 regulation; updating of mar within 24 hours of receipt of new orders; updating treatment plan for psychotropic medication, resident rights review required annually; staff in charge posting should be updated per shift; resident's orientation should include facility's emergency response review; and discontinued medication should be removed from the medication administration record (mar) in a timely manner. Please complete the columns for "description of action to be taken: and "date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office within 10 calendars of receipt. If you have any questions, contact the licensing inspector at (757) 439-6815. Plan of correction due 7-29-19.

Violations:

Standard #:	22VAC40-73-120-B
Description:	Based on record review, document review and staff interview, the facility failed to ensure staff receiving orientation acknowledged receipt of completion of orientation. Evidence: 1. On 7-9-19 during a review of the sampled staff records with staff #1 and #3, it was revealed that two staff orientation record did not include the date and signature of the staff's acknowledgement of orientation: (a) nursing department staff #5, certified nursing aide, date of hire 11-26-18 and (b) dining services department staff #6,dietary aide, date of hire 3-11-19. 2. Staff # 1 and #3 acknowledge the staff's signature was not documented acknowledging orientation training on the facility's orientation form.
Plan of Correction:	1. Staff #5 and #6 received orientation in a timely manner and the orientation forms have been corrected and acknowledged by the appropriate staff member to include signature and verification date of orientation. The original forms were incorrectly signed by the staff performing the training. 2. Staff responsible for training were in-serviced regarding the requirement for the staff member being trained to sign and date the form in acknowledgement that the orientation occurred. 3. The administrator/ designee will audit staff records monthly for a period of three months to ensure orientation forms are acknowledged appropriately. The Administrator/designee will review the audit results for patterns and trends and report findings to the Quality Assurance Committee.
Standard #:	22VAC40-73-210-F
Description:	Based on record review, document review and staff interview, the facility failed to ensure a staff training document included all of the required training hours. Evidence: 1. On 7-9-19 during a review of the sampled staff record with staff #1 and #3, due to computer access issue, the review of staff training information was presented via paper documentation. A review of the facility's "inservice record of attendance" presented by staff #1 reveal staff #4's record noted 1.5 hours of the required 4.0 hours of mental health training.
Plan of Correction:	1. The staff member in question has received the required four hours of mental health training. 2. In-service records for all current staff will be audited to ensure all required training hours have been met in a timely manner. Staff responsible for training were in-serviced on the regulatory requirements and timeframes for training. 3. The Administrator/ designee will conduct audits monthly for a period of three months to ensure all required training is completed in a timely manner. The Administrator/designee will review the audit results for patterns and trends and report findings to the Quality Assurance Committee.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, document review and staff interview, the facility failed to ensure direct care staff receive certification in first aid within 60 days of employment. Evidence: 1. On 7-9-19 during a review of staff records with staff #1 and staff #3, it was revealed that direct care staff #5 documented date of hire as 11-26-18. A review of the staff #5's first aid card noted a date of 4-11-19. 2. Staff #1 and #3 acknowledge the staff first aid was not completed within 60 days of hire.
Plan of Correction:	1. Staff records have been audited to ensure all direct care staff have current first aid certification or received the training within 60 days of employment. 2. The staff responsible for hiring and training have been in-serviced regarding the training and/or certification requirements. 3. The Director of Nursing/ designee will audit staff training/ certification records monthly for a period of three months to ensure the requirement is met. The Director of Nursing/ designee will review the audit results for patterns and trends and report findings to the Quality Assurance Committee.
Standard #:	22VAC40-73-260-C
Description:	Based on document review and staff interview, the facility failed to ensure the posted listing of staff with first aid and cardiopulmonary resuscitation (cpr) was kept up to date. Evidence: 1. On 7-9-19 during a review of the facility's first aid and cpr listing with staff #1, it was revealed that the list was not updated to include all staff with first aid and/or cpr. 2. A review of the facility's "TN/TH CPR & First Aid Certifications" list on 7-9-19 did not include the following staff: (a) staff #4- Licensed practical nurse (LPN), date of hire 9-26-17 and (b) staff #5- certified nurse aid (CNA), date of hire 11-26-18. 3. Staff #1 acknowledge the first aid/cpr posted listing did not include all certified staff.
Plan of Correction:	The facility first aid and CPR listing was updated to include all staff with certification. 2. The staff responsible for updating the certification listing was in-serviced in regards to the importance of keeping the list current. 3. The Administrator/ designee will audit monthly the certification listing to ensure the list is current and revised as needed. The Administrator/ designee will review the audit results for patterns and trends and report findings to the Quality Assurance Committee.
Standard #:	22VAC40-73-440-D
Description:	Based on record review, document review and staff interview, the facility failed to ensure the uniformed assessment instrument (uai) was completed correctly. Evidence: 1. On 7-8-19 during a review of the sample resident record with staff #2, it was revealed resident #4's uai document dated 5-17-18/ updated 12-21-18 noted resident #4 need for toileting was checked yes, however, the type of assistance needed was not documented; the ISP dated 12-21-18 documented use of grabbar and raised toilet seat. 2. Further review of resident #4's uai with staff #2, also noted walking and stairclimbing assessed as "not performed". According to staff #2, resident #4 is able to walk and climbstairs. A review of the ISP dated 12-21-18 stairclimbing and walking not documented as an assessed need for resident #4. 3. Staff #2 acknowledged the uai for resident #4 was not accurately completed.
Plan of Correction:	1. The UAI for resident #4 was updated to ensure accuracy and completeness. 2. UAIs will be audited to ensure completeness and accuracy and ensure that they match the ISP. 3. The Director of Nursing/ designee will audit all annual UAIs and ISPs that are due that month for a period of three months to ensure completeness and accuracy. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-440-H
Description:	Based on record review, document review and staff interview, the facility failed to ensure an annual reassessment using the uniformed assessment instrument (uai) was utilize to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 7-8-19 during a review of the sample resident's record with staff #2, a review of resident #2's record revealed the resident's uai document was dated 5-1-18 and 6-30-18; resident's date of admission documented 5-30-18. The last uai in the record was dated 6-30-18. 2. Staff #2 acknowledged resident #2's uai was not updated.
Plan of Correction:	1. The UAI for resident #2 was updated and completed. 2. UAIs will be audited to ensure they are completed annually during the month they are due. 3. The Director of Nursing/ designee will audit all annual UAIs that are due that month for a period of three months to ensure they are completed timely. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-450-D
Description:	Based on record review, document review and staff interview, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). Evidence: 1. On 7-8-19 during a review of the sample resident's record with staff #2, resident #5's ISP did not include all of the services provided by the hospice agency. 2. On 7-9-19 the inspector was presented a copy of resident #5's hospice contract with services. A review of resident #5's hospice contract indicated resident to receive nursing services, social worker, chaplain and care aide. Resident #5's ISP reviewed on 7-8-19 with staff #2 did not include all hospice services identified in contract reviewed on 7-9-19.
Plan of Correction:	1. The ISP for resident #5 was updated to include services that are provided by the hospice agency. 2. ISPs will be audited for all hospice residents to ensure the information is included. 3. The Director of Nursing/ designee will audit all ISPs for hospice residents monthly for a period of three months to ensure the services being provided by hospice are included. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, document review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. The plan shall also indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person who was involved in the development of the plan shall be included. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. On 7-8-19 during a review of the sample resident's record with staff #2, a review of resident #1's updated ISP was not dated by the resident and/or legal representative. Resident #1's record indicated a date of admission 3-1-19 and a preliminary ISP dated 3-1-19. Resident #1's ISP was reviewed and updated; however, the ISP did not include a date of resident and /or representative review. 2. Staff #2 acknowledge resident #1's updated ISP did not include date of review by resident/legal representative.
Plan of Correction:	1. The ISP for resident #1 was signed by the resident. 2. ISPs will be audited to ensure they are signed by the resident and/or resident representative. 3. The Director of Nursing/ designee will audit all ISPs that have been completed monthly for a period of three months to ensure they have been signed by the resident and/or resident representative. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-450-F
Description:	Based on record review, document review and staff interview, the facility failed to ensure a resident's individualized service plan (ISP) was as needed as the condition of the resident changes. The review shall and update shall be performed by a staff person with the qualifications specified in subsection B of the this section of the regulation and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: 1. On 7-8-19 during a review of the sampled resident's record with staff #2, resident #2's record noted on 5-31-19 the resident's need for wound care, wounds on leg (statis). According to staff #2, resident #2 did not receive wound care services from a home health agency, the wound care services were being performed by facility's nurse ; resident receiving care for "weeping" to legs. 2. A review of resident #2's ISP dated 3-18-19 did not document the change in the resident's condition; wound care services noted in the record on 5-31-19 and being provided by facility staff. 3. Staff #2 acknowledged resident #2's ISP was not updated to reflect the resident's need for wound care services.
Plan of Correction:	1. The ISP for resident #2 was updated to include wound care. 2. All ISPs will be audited to ensure changes in resident condition are updated in the ISP as needed. 3. The Director of Nursing/ designee will audit ISPs for any resident with a change in their condition monthly for a period of three months to ensure that any changes in a resident?s condition are updated in the ISP if needed. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, document review and staff interview, the facility failed to ensure it followed its medication management plan for disposal/removal of medication/medication storage. Evidence: 1. On 7-8-19 during the medication pass observation with staff #4, resident #2's prn Refresh eye drops was observed on the medication cart. According to staff #2, resident #2 no longer received Refresh eye drop, the treatment was discontinued on 4-4-19; no current order in record for Refresh. 2. On 7-8-19 during medication pass observation with staff #4, Cymbicort was observed at resident #6's bedside. According to staff #4 and documentation from resident #6's last hospital admission/discharge the Cymbicort was discontinued on 6-28-19; no current order in record for Cymbicort. Resident #6's record did not include current physician's order for resident to keep medication at bedside. Resident #6 was also observed with Ventolin HFA and Aspercreme at bedside, on night stand; no physician order to keep at bedside. A review of resident uniformed assessment instrument (uai) dated 11-1-18 did not indicate resident to keep medication at bedside. 3. Staff #4 acknowledge the discontinued medication was observed on the cart for resident #2 and at bedside for resident #6.
Plan of Correction:	This plan of correction is respectfully submitted as evidence of alleged compliance. The submission is not an admission that the deficiencies existed or that we are in agreement with them. It is an affirmation that corrections to the areas cited have been made and that the facility is in compliance with participation requirements. 1. The discontinued medication for resident #2 was removed from the medication cart. The discontinued medication for resident #6 was removed from her room. The medications that were at bedside were removed and placed in the medication/treatment cart. 2. All medication carts will be audited to ensure discontinued medications have been removed. Resident rooms will be inspected to ensure any bedside medications have physician?s orders. 3. The Director of Nursing/ designee will conduct monthly audits for a period of three months to ensure that medication carts do not contain discontinued medications and that any bedside medications have a physician?s order. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-680-I
Description:	Based on record review, document review and staff interview, the facility failed to ensure the medication administration record (mar) included all of the required information. Evidence: 1. On 7-8-19 during the medication pass observation with staff #4, the mar for resident #2 did not include the diagnosis for the following: Tylenol 325 and Salonpas topical patch. 2. Staff #4 acknowledged the diagnosis was not available on the resident #2's mar.
Plan of Correction:	1. Diagnoses were received from the physican on resident #2 for the Tylenol and Salonpas. 2. All MARs will be audited to ensure all medication orders have a diagnosis indicated on the order. 3. The Director of Nursing/ designee will audit ten MARs monthly for a period of three months to ensure that all ordered medications have a diagnosis listed. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-680-M
Description:	Based on document review, observation and staff interview, the facility failed to ensure medications ordered for PRN administration was available, properly labeled for specific resident, and properly stored at the facility. Evidence: 1. On 7-8-19 during the medication pass observation with staff #4, medication ordered for PRN administration was not available for resident #6, physician order dated 7-3-19: (a) Albuterol sulfate; (b) Ipratropium albuterol; (c) Nitroglycerin and (d) Robitussin cough syrup. 2. On 7-8-19 a medication observation with staff #4, PRN medication was not available for resident #2. physician order dated 6-7-19 for Lorazepam. 3. Staff #2 and #4 acknowledged the residents PRN not available during inspector's reviews on 7-8-19.
Plan of Correction:	1. The family for resident #6 was contacted to obtain all medications that have been ordered by the physician. 2. The medications carts will be inspected to ensure all ordered medications are available. 3. The Director of Nursing/ designee will inspect the medication cart for ten residents monthly for a period of three months to ensure that all ordered medications are available. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-980-A
Description:	Based on document review, staff interview and observation, the facility failed to ensure the first aid kit on hand in the building and on the vehicle used to transport residents contained all required items. Evidence: 1. On 7-8-19 during a check of the facility's first aid kit check with staff #4, the antiseptic cream's expiration date was dated 2/2019. 2. A check of the first aid kit for the vehicle used to transport residents with staff # 8, did not contain scissors. 3. Staff #4 acknowledged the first aid kits contained expired items and vehicle first aid kit was missing scissors.
Plan of Correction:	1. The expired items in the facility first aid kit were immediately replaced to be in compliance. Scissors were immediately added to the vehicle first aid kit to be in compliance. 2. Staff responsible for first aid kit audits will perform weekly checks of the first aid kits to ensure that all required items are included and items with an expiration date are in compliance. 3. The Administrator/ designee will audit all first aid kits weekly for a period of three months to ensure items are in compliance. The Administrator/ designee will review the audit results for patterns and trends and report findings to the Quality Assurance Committee.