VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Dunlop House
235 Dunlop Farms Boulevard
Colonial heights, VA 23834
(804) 520-0050

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: July 23, 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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

On 07/23/2019 a focused monitoring inspection to review compliance for previously cited violations was conducted at the facility by the assigned licensing inspector. The licensing Administrator for the Central region was also present throughout this inspection. The two VDSS representatives reviewed facility records, interviewed facility staff, observed a medication administration pass, the breakfast and lunch meal, and parts of the facility?s physical plant. When physician orders, such as Artificial Tears are ordered for the middle of the night ensure that the order stipulates whether the resident should be woken to administer the medication. The non-compliance revealed during this inspection is contained within this report. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions please feel free to contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov if you have any questions. The inspection was conducted between the approximate hours of 8:55a.m and 6:46p.m.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on a review of resident records and interview with staff, the facility failed to determine whether placement in a special care unit is appropriate prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment. Evidence: Resident #8 The resident record did not contain the determination and justification for the decision to place the resident in a safe, secure environment. Upon request, the Administrator and Executive Director did not provide the requested documentation.
Plan of Correction:	FACILITY RESPONSE- "Residents determined to have a need for placement in a secured special care unit will have audit of records to ensure required documentation. Admissions Director, DON, Administrator and/or Executive Director will review documentation for all current and new admissions to secured special care unit".
Standard #:	22VAC40-73-40-B-6
Description:	Based on the review of facility records and interviews conducted with the facility?s Administrator and Executive Director on 07/23/2019, the facility failed to exercise general supervision over the affairs of the licensed facility and failed to ensure that documentation of resident care, is maintained as required. Evidence: Resident #4?s Medical History/Physical Exam document dated three days prior to admission on 7/16/2019, noted no mention of the resident?s left arm being in a cast. The resident?s Service Notes documented that the resident was admitted to the facility?s safe and secure environment on 07/19/2019 with her left arm in a cast. The facility did not submit for the inspector?s review documented evidence that the facility?s physician had been notified of the resident?s change in condition that occurred after the completion of the Medical History/Physical Exam but prior to admission to the facility in order for the physician to determine an appropriate plan of care.
Plan of Correction:	FACILITY RESPONSE- "Resident?s cast was applied prior to the completion of H&P and not addressed by MD. ISPs will include any care needed for similar situations whether or not documented on H&P by MD. DON, Administrator and/or Executive Director will review ISPs for accuracy".
Standard #:	22VAC40-73-220-A
Description:	Based on the review of facility records and interviews conducted with the facility?s Administrator and Executive Director on 07/23/2019, the facility failed to ensure that before direct care or companion services are initiated, the facility obtain all of the required documentation in writing. Evidence: RESIDENT #2 On 7/23/2019 during interviews with the facility Administrator and upon request, the facility Administrator and Executive Director did not submit for the inspector?s review documented evidence of the following: 1. Written documentation containing information on the type and frequency of services to be delivered to the resident by private duty personnel, a review of the information to determine if it is acceptable, and notification to the home care organization regarding any changes needed. 2. Documented evidence that, prior to coming in contact with residents, the results of a risk assessment documenting the absence of tuberculosis in a communicable form were maintained at the facility or the licensed home care organization. 3. Documented evidence that the facility had provided orientation and training to the private duty personnel regarding the facility's policies and procedures related to the duties of private duty personnel. 4. How the facility was monitoring the delivery of direct care and companion services to the resident by private duty personnel.
Plan of Correction:	FACILITY RESPONSE-"Facility will review documentation on file for any private duty personnel currently employed by residents and ensure that Private Duty staff employed by resident or their family members has received orientation and training to facility policies and procedures related to duties of private duty personnel and TB screening prior to contact with residents of the facility. Resident and/or family will be required to provide details of duties expected of the personnel they employ and such duties will be documented on resident ISP, if not already documented. DON, Administrator and/or Executive Director to review documentation and monitor delivery of care."
Standard #:	22VAC40-73-450-A
Description:	Based on the review of facility records and interviews conducted with the facility?s Administrator and Executive Director on 07/23/2019, the facility failed to ensure that the resident?s preliminary plan of care was developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Evidence: RESIDENT#4- Documented date of admission 07/18/2019 Facility records that were submitted for the inspector?s review noted the following: (1)- 07/19/2019 the facility?s Service Notes in part noted ?Resident arrived to facility in family car with both daughters. Resident pleasant has cast on L arm from fall while on vacation daughter stated resident?s skin very thin and gets skin tears easily?. The resident?s 07/19/2019 ISP that was submitted for the inspector?s review did not contain documented evidence that the facility had developed a preliminary plan of care for direct care staff to implement regarding the care needs for the resident?s left arm. (2)- The resident?s 07/16/2019 Assessment of Serious Cognitive Impairment noted under the heading ?Cognitive Functioning- ?Reasoning, Judgement and Insight Poor.? The resident?s 07/15/2019 Uniform Assessment Instrument (UAI) noted the following : under the heading- ?Oriented? facility staff noted ? Disoriented ?Some spheres, all the time and under the heading ?Spheres affected, facility staff noted ?time, place.? Under the heading Level of Care Approved- facility staff noted ?Assisted Living; Memory Care/Transitions?. Care needs pertaining to disorientation and poor insight were not addressed on the preliminary ISP. (3)- An Educational / Employment History document submitted for the inspector?s review noted under the heading Personal / Social Data : Hobbies and Interests: ?Reading, needlework, lately not much.? The facility?s 07/19/2019 computerized preliminary care plan that was submitted for the inspector review noted under the category of Activity Interests and Background Information, the Services to be Provided was blank. Under the heading of ?Who Provided/Goal Date? it stated ?All staff should be aware of social needs and interest. Activity staff.? The 7/19/2019 computerized preliminary care plan addressed that activity staff should be aware of resident social needs but services to be provided were not address even though resident interests were documented in the resident record. Resident #7 (date of admission 7/12/2019) The UAI dated 07/03/2019 was documented to show that supervision was required for dressing. The preliminary Individualized Service Plan (ISP) dated 07/12/2019 was checked to show resident ?completes dressing on own.? Residents #4 and #7 were admitted to the safe, secure environment. The identified need to a secure environment was not addressed on either preliminary ISP.
Plan of Correction:	FACILITY RESPONSE- "ISPs will be reviewed to ensure accuracy of needs, activities of choice and notation of need for SCU are documented. DON, Administrator, and/or Executive Director will review with each update to UAI/ISP".
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interviews conducted with the facility?s Administrator and Executive Director on 07/23/2019, the facility failed to update a resident?s Individualized Service Plan (ISP) as needed as the condition of the resident changes. EVIDENCE: RESIDENT #2 1. The resident?s 04/11/2019 ISP that was submit for the inspector? review noted DESCRIPTION OF NEED ?Behavior?. Under the heading SERVICES TO BE PROVIDED the facility noted- ?Resident becomes anxious and irritated from other residents at times. Has gotten in confrontation with other residents. Staff will intervene and redirect resident to her room or quiet area away from other residents when this occurs.? However, upon request the facility Administrator and Executive Director did not provide verbal or documented information of possible triggers for the resident that would offer guidance and a plan of care for facility direct care to implement to avoid resident?s anxious behavior. During interviews facility staff did not provide when asked of a specific incident that concluded the resident to have the inability to be in the presence of other facility residents. The facility Administrator stated during interviews that the resident was receiving direct care services from a private sitter. The resident?s 04/11/2019 ISP that was submitted for the inspector?s review does not mention an identified need for a private sitter, nor does the ISP identified any services that the identified private sitter would provide to resident #2. 2. The facility?s Dietary Order Sheet dated 04/22/2019, that was submitted for the inspector?s review noted the following: ?Recommend diet: Mech soft with no items with hulls (e.g., corn, peas) or skins (e.g., grapes, raw tomatoes) with thin liquids?. During interviews, the Administrator and Executive Director acknowledged the Dietary Order Sheet document identifying the weight loss as a service need. The resident?s 04/29/2019 ISP that was submitted for the inspector? review did not address this identified service need. Resident #4 Facility records that were submitted for the inspector?s review note that upon admission the resident was admitted to the facility?s safe and secure environment. The resident?s Service Notes that were submitted for the inspector?s review in part noted the following: (1)-07/20/19- ?redirect banging on doors to be let out. Redirected X2. (3)-07/21/2019- ?Cont. to bang on door, redirected without difficulty. (3)-07/22/2019 ?New resident adjusting to facility verbal ambulates Resident came to doors X 4 trying to open by banging on them easily redirected by staff.? The resident?s 07/19/2019 ISP was not updated to identify a clear and proactive plan for facility direct care staff to implement that offers alternatives to minimize the effects and duration the resident?s observed exit seeking behaviors.
Plan of Correction:	FACILITY RESPONSE-"ISPs will be reviewed to ensure accuracy of dietary needs/preferences and address weight loss as needed. 30 day comprehensive ISPs to address any resident behavioral issues/concerns and interventions to attempt to minimize them. DON, Administrator, and/or Executive Director will review with each update to UAI/ISP."
Standard #:	22VAC40-73-580-F
Description:	Based on a review of resident records, the facility failed to implement required interventions as soon as a nutritional problem is suspected. Evidence: The resident?s 04/29/2019 ISP that was submitted for the inspector? review noted under the heading DESCRIPTION OF NEED- ?Meal Prep/Wt Loss; under the heading SERVICESTO BE PROVIDED the facility noted in part- Resident will receive three nutritious and well balanced per day.? Upon request, the facility did not submit for the inspector?s review, documented evidence indicating that interventions, including weighing the resident at least monthly to determine whether the resident has significant weight loss, were implemented as soon as a nutritional problem was suspected. Resident #8 Resident #8 was transferred from the assisted living side of the facility to the safe, secure environment. The ISP was not updated as the condition of the resident changed.
Plan of Correction:	FACILITY RESPONSE-"ISPs will be reviewed to ensure accuracy of needs, to include notation of need for SCU and any dietary/weight loss concerns. DON, Administrator, and/or Executive Director will review with each update to UAI/ISP".
Standard #:	22VAC40-73-680-D
Description:	Based on observation and the review of resident records on 7/23/2019, the facility failed to ensure that medications were 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 for documenting all medications administered or omitted. EVIDENCE: The Medication Administration Records showed no documentation for the following to indicate whether the medications were administered or omitted: 1. Resident # 6 June 2019 ? 11 administration times with no documentation July 2019 ? 7 administration times with no documentation 2. Resident # 5 June 2019 ? 9 administration times no documentation 3. Resident #7 July 2019 ? 14 administration times with no documentation.
Plan of Correction:	FACILITY RESPONSE-"Electronic MARs will be reviewed on a daily basis to monitor for omission of medications. Any outstanding issues will be addressed and any technical difficulties resulting in documentation errors or use of alternate ?paper system? will be reconciled on a daily basis. DON and shift charge nurse to review daily".
Standard #:	22VAC40-73-680-H
Description:	Based on a review of resident records, the facility failed to document on a medication administration record (MAR) all medications administered to residents at the time the medication is administered. Evidence: Resident #1 Resident was prescribed Amox-Clav 500-125mg Take one tablet by mouth 2 times a day x7 days for infected lip bite on 06/17/2019. The prescription was filled on 06/18/2019 per copy of medication bottle label. The June 2019 MAR documentation showed the first dose was administered on 06/20/2019. Nurses note documentation on 6/19/2019 at 2200 states, ?late entry ABT due lip infection, no adverse reaction?? There is no documentation on June 2019 MAR for 6/19/2019 that the medication was administered or omitted.
Plan of Correction:	FACILITY RESPONSE-"Electronic MARs will be reviewed on a daily basis to monitor for omission of medications. Any outstanding issues will be addressed and any technical difficulties resulting in documentation errors or use of alternate ?paper system? will be reconciled on a daily basis. DON and shift charge nurse to review daily."
Standard #:	22VAC40-73-930-D
Description:	Based on a review of resident records, the facility failed to include the inability to use a call bell system in the resident?s individualized service plan (ISP) including specifying the minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs. Evidence: Residents #4, #7, and #8 reside on the safe, secure environment. The inability to use the call bell system was not addressed on any of the three residents? ISP
Plan of Correction:	FACILITY RESPONSE-"ISPs will be reviewed for accuracy and to include resident?s ability to use call bell system. DON, Administrator, and/or Executive Director will review with each update to individual ISPs."