VIRGINIA DEPARTMENT OF SOCIAL SERVICES

DLM Corporation
3502 Chamberlayne Avenue
Richmond, VA 23227
(804) 357-6743

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: June 27, 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

Technical Assistance:

280.D - The facility shall maintain staff on duty and on site when at least one resident is present. 530.C - Residents cannot be locked out or restricted from entering the facility and/or their room. The facility shall provide freedom of movement.

Comments:

An unannounced monitoring inspection was conducted at the facility on 6/27/2019 by three licensing representatives to follow-up on a self reported incident of a resident's death. The licensee reported that the facility does not maintain staff on duty and in the building during weekdays as all residents at the facility attend day programs. An investigation of the self-reported incident found that two residents, who were temporarily not involved in a day program, were left unsupervised in the community and/or at the facility due to the facility being locked and staff not being maintained on site. Violations were cited based on the investigation. The facility has 10 calendar days from receipt of the inspection reports to complete a plan of correction, sign the inspection reports and return them to the licensing office. A copy of the inspection reports shall be retained to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS website within 15 calendar, regardless of whether the plan of correction is completed .Just writing the word ?corrected? is not acceptable. The plan of correction shall include the following: (1) Step(s) the facility will take to correct the violations cited; (2) Measures that will be put in place to prevent reoccurrence of each violation; (3) Person(s) responsible for implementation and monitoring of preventive measures; and (4) Date by which each violation will be corrected.

Violations:

Standard #:	22VAC40-73-150-C
Description:	Based on observations, interviews with a resident and a family member and an investigation of a self reported incident on 6/27/2019, the administrator has failed to ensure that care is being provided in a manner that protects the health, safety and well being of resident in care. Evidence: 1. It was reported through interviews with a family member and a resident (#1) that residents cannot freely enter the facility during day hours as the facility is locked and there is no staff on site. 2. On 6/26/2019 a resident (#2) was found unsupervised on the front steps of the facility by a licensing representative, the facility was locked and there was no staff found on site. 3. An investigation of a self reported incident on 6/27/2019 found that a resident (#1) returned to the facility on 6/13/2019 from a temporary stay at an inpatient mental health treatment facility. The administrator stated that all residents at the facility attend day programs and that resident # 1 was awaiting day program placement. A family member of resident # 1 reported that the resident did not want to attend a day program and preferred "being at home". Resident # 1 died from an unknown cause while unsupervised in the community awaiting the placement.
Plan of Correction:	Due to the Commonwealth of Virginia, residents have a right to freedom of movement. Resident # 1 chose to visit his family in the community rather than remain in the facility during the day. He is assessed at the residential level of care. He was never locked out of the facility. A sign is always posted on the facility door indicating how to reach the administrator, who is (or his designee) available during the day and able to return to the facility within 15 minutes. They can also wait or seek assistance at the facility across the street, also owned by the licensee. Resident # 1 never indicated to the administrator or staff that he "preferred being at home" during the day. The individual was a resident of the facility for approximately ten years prior to his recent discharge from Central State Hospital. Had the resident ever stated that he wanted to remqain at the home provisions would have been made to have a staff member at the home with him. As this resident is deceased the allegations made are simply that "allegations" and as such are unsupported. The _____ concerns about his being locked out of te facility were never shared with the administrator during the resident's ten year stay at the facility, so (the administrator) was never given the opportunity to address them.
Standard #:	22VAC40-73-280-D
Description:	Based on an observation and interview with a resident, the facility failed to maintain one staff member on duty at all times when at least one resident is present. Evidence: Resident # 1 was observed at approximately 8:00 am on 6/26/2019 by licensing staff sitting on the front steps of the facility. Resident # 1 informed licensing staff that he was waiting for transportation to an appointment at the VA hospital and that there was no staff in the building. Resident # 1 shared that he walked to another licensed facility, operated by the same provider, as staff left the building and locked the facility's doors around 7 am. The resident further shared that he walked back to DLM Palace shortly thereafter to wait for transportation to his appointment. Resident # 1 reported that his appointment was for 10 am. The licensing representative confirmed that the facility was locked and that no staff was on site by knocking on the door and ringing the doorbell of the facility with no response.
Plan of Correction:	Transportation arrangements to the VA hospital for resident # have been directed to _________ (the resident's mental health services provider).
Standard #:	22VAC40-73-340-B
Description:	Based on a review of a resident's file and interviews with the facility's administrator, the administrator failed to document that the resident's psychosocial and behavioral history were reviewed and used to help determine the appropriateness of the resident's admission. Evidence: A review of the file for resident # 1 by two licensing representatives on 6/27/2019 found a discharge plan dated 6/13/2019 from an inpatient mental health treatment facility. There was no documentation in the file to support that the facility used the information to determine the resident's appropriateness for admission to the facility.
Plan of Correction:	The Discharge Coordinator from the state hospital should never released resident # 1 without having services in place. Wrap around services should have been coordinated prior to his release. In the future, the administrator will review all documents and the level of care received from ______ or any other hospital to ensure that the placement is appropriate. If a resident has been hospitalized for 80 days, when they return to the facility they will be considered a new admission.
Standard #:	22VAC40-73-390-A
Description:	Based on a review of a resident's file on6/27/2019, a comprehensive resident agreement was not completed for one resident. Evidence: The facility's administrator reported that the facility had a bed hold policy, but was unable to produce one at the time of the inspection. Licensing staff proceeded to review the agreement for resident # 1 in an attempt to ascertain the facility's bed hold policy and found that the agreement had only two pages and was missing required elements listed in specific acknowledgements.
Plan of Correction:	The resident agreement has been updated to include all elements.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of a resident's file on 6/27/2019 by two licensing representatives, the resident's individualized service plan was not updated at least every 12 months or as the condition of the resident changed. Evidence: Resident # 1 returned to DLM Palace on 6/13/2019 after a temporary stay at an inpatient mental health treatment facility with a recommendation for outpatient mental health services. The service plan in the file of resident # 1 was dated 2017 and had not been updated at the time of the resident's return to reflect the resident's current mental health services needs.
Plan of Correction:	When a resident is discharged from a hospital or mental health facility, the administrator or his designee will update his ISP to reflect his current needs.
Standard #:	22VAC40-73-510-D
Description:	Based on a review of a resident's file on 6/27/2019 by two licensing representatives, the facility failed to document (1) unsuccessful efforts to obtain recommended mental health services, (2) how the facility plans to ensure that failure to obtain the recommended mental health services will not compromise the health, safety or rights of the resident and others who come into contact with the resident, and (3) additional steps the facility will take to find alternative providers to meet the resident's needs. Evidence: 1. Resident # 1 was admitted to a public mental health facility on 5/10/2019 for inpatient treatment and returned to DLM Palace on 6/13/2019. 2. The discharge plan from the mental health facility detailed a recommendation and need for continued outpatient mental health treatment. 3. The licensee/administrator reported on 6/27/2019 that resident # 1 had been referred but was currently not involved in any outpatient mental health treatment. 4. The facility's administrator and the behavioral health case manager who transported the resident to the facility reported that the resident was hallucinating (that he was Jesus) at the time of his return to the facility. 5. The file review found no documentation of efforts to obtain the recommended services, no documentation of the facility's plan to ensure that failure to obtain the recommended services would not compromise the health, safety and rights of the resident or others, and no documentation of any additional steps the facility took to find to find alternative providers.
Plan of Correction:	The administrator will ensure that before a resident is discharged from ______ hospital back to the facility that mental health services are in place in the community.