VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harbor's Edge
One Colley Avenue
Norfolk, VA 23510
(757) 233-0475

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Aug. 28, 2019 and Aug. 30, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This was an unannounced annual monitoring inspection conducted by a Licensing Inspector from the Eastern Regional Office. The inspection was conducted on August 28, 2019 from 9:04 a.m. until 3:32 p.m. and on August 30, 2019 from 9:45 a.m. until 4:58 p.m. There were 45 residents in care, to include 14 residents in Memory Support (memory care unit). The administrator for the assisted living was present during inspection. During the inspection, a tour of the building and grounds was conducted. The lunch meal was observed in the memory care unit as well as an activity. The facility was preparing for an evening "Luau" event in both assisted living and memory care. A medication observation and a check of the medication cart was conducted on cart 3, cart 7 and in memory care. Resident and staff records were reviewed, to include a review of criminal background checks for all new staff since the previous inspection. Resident interviews were also conducted. The facility's emergency preparedness supplies and equipment was also reviewed. During the inspection, there was a discussion regarding requirements for all private duty personnel in the facility and the new Disclosure form for new and current residents. Also discussed the facility's electronic system and records to include Individualized Service Plan (ISP) signatures and start dates .Discussed fall risk ratings and the Healthcare oversight. Review all forms for accuracy and completeness. The facility received violations under Personnel, Admission, Retention & Discharge of Residents, Resident Care and Related Services, Buildings and Grounds, and Part 10- Safe, secure environment. All areas of non-compliance were reviewed with the Administrator during the exit interview at the end of each day. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction should include 1. Step(s) to correct the non-compliance with the standards 2. Methods to prevent re-occurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventive action.

Violations:

Standard #:	22VAC40-73-1180-B
Description:	Based on observation and interview, the facility failed to ensure when there are indications that ordinary materials or objects may be harmful to a resident, these materials or objects shall be inaccessible to the resident except under staff supervision. Evidence: 1. During the tour of the memory care unit with staff #1, the drawer in the back living room contained 11 bottles of acrylic paint. The drawer was unlocked and accessible to residents in the unit. 2. During interview, staff #1 acknowledged the unlocked drawer containing the paint bottles.
Plan of Correction:	No residents were adversely affected by the deficient practice. Bottles of acrylic paint were removed from resident access. All art supplies will be kept in a locked compartment. Daily rounding will be performed by Unit Manager or designee to ensure that no ordinary materials or objects that have the potential to harm a resident are accessible. Any findings identified will be corrected, staff counseled and reeducated as appropriate. The results of the rounds will be tracked and presented to the campus wide QAPI committee.
Standard #:	22VAC40-73-220-B
Description:	Based on observation, record review, and interview, the facility failed to ensure all of the requirements were met when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents, to include: a description of the type and frequency of services to be delivered, obtained in writing prior to the initiation of services, tuberculosis (TB) reports documenting the individual is free from tuberculosis in a communicable form, verification that orientation and training was provided to the private duty personnel regarding the facility's policies and procedures to the duties of private duty personnel, verification that the private duty personnel is qualified for the types of direct care or companion services they are providing, and an original criminal history record report issued by the Virginia Department of State Police. Evidence: 1. During a medication observation pass with staff #6 in the memory care unit, resident #4 was observed sitting in the front TV room next to a male who staff #6 identified as resident #4's private duty. 2. During interview, staff #2 identified the private duty personnel as private duty #1. Staff #2 indicated private duty #1 was hired by the resident's family and was not affiliated with a licensed home care organization. Licensing Inspector requested private duty #1's record. Staff #2 stated there was no record on file for private duty #1, to include verification of a description of the type and frequency of services to be delivered, obtained in writing prior to the initiation of services,a tuberculosis report documenting the absence of TB in a communicable form, verification that orientation and training was provided to the private duty personnel regarding the facility's policies and procedures to the duties of private duty personnel, verification that the private duty personnel is qualified for the types of direct care or companion services they are providing, and an original criminal history record report issued by the Virginia Department of State Police. 2. Staff #2 provided a private duty record for resident #4's other private duty, private duty #2. According to staff #2, private duty #2 is not affiliated with a licensed home care organization. The record for private duty #2 did not contain a description of the type and frequency of services to be provided or verification of the staff person's qualifications to provide such services. 3. During interview, staff #1 and staff #2 acknowledged the missing information for private duty #1 and #2.
Plan of Correction:	No residents were adversely affected by the deficient practice. All of the missing required information (verification of type and frequency of services delivered, TB testing, orientation, qualifications, criminal record report) will be obtained. A complete audit of records for all private duty personnel who are not employees of a licensed home care organization that provide direct care or companion services to residents will be conducted to ensure that the requirements of the 22VAC40-73-(3)-220-B are met. A list of all private duty personnel will be maintained and the required records will be audited once a month for 3 months by Unit Manager or designee. Any variances identified will be corrected. The results of the audit will be tracked and trended and presented to the campus wide QAPI committee.
Standard #:	22VAC40-73-310-H
Description:	Based on observation, record review, and interview, the facility failed to ensure it did not retain individuals with psychotropic medications without a treatment plan; in accordance with ? 63.2-1805 D of the Code of Virginia. Evidence: 1. During the medication observation pass, staff #4 administered Venlafaxine (Effexor) 37.5 mg to resident #2. Review of resident #2's record revealed the resident had a physician's order dated 7-30-18 for Venlafaxine (Effexor) 37.5mg for Depression. In addition, the resident had a physician's order for Cymbalta 60mg for depression. The resident's record did not contain a psychotropic treatment plan for the Venlafaxine (Effexor) or the Cymbalta 60mg. 2. During a medication observation with staff #5, staff #5 administered Buspirone 5mg to resident #11. Review of resident #11's record revealed a physician's order dated 6-17-19 for Buspirone 5mg. Resident #11's record did not contain a psychotropic treatment plan for the Buspirone 5mg. 3. During interview, staff #2 and staff #3 acknowledged there was no psychotropic treatment plan on file for aforementioned medications for resident #2 and resident #11.
Plan of Correction:	No residents were adversely affected by the deficient practice. A treatment plan for all residents with orders for psychotropic medications have been put in place. A complete audit of all residents with orders for psychotropic medications has been completed to ensure compliance. Any findings have been corrected. Prescribing physician will complete the psychotropic treatment upon the issuance of the order. Unit Manager or designee will conduct weekly record audits on all new psychotropic medications for 3 months to ensure that treatment plans are present for all psychotropic medications. Any variances identified will be corrected, staff counseled and reeducated as appropriate. The results of the audit will be tracked and trended and presented to the campus wide QAPI committee.
Standard #:	22VAC40-73-450-E
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was signed and dated by the resident or his legal representative. Evidence: 1. During review of resident records with staff #1 and staff #2, resident #1's most current ISP completed on 5-16-19 was not signed by the resident or the resident's legal representative. 2. Resident #7's ISP completed on 7-23-19 was not signed by the resident or the resident's legal representative. The most current signed ISP on file for resident #7 was dated 8-30-17. 3. During interview, staff #2 and staff #3 acknowledged the aforementioned ISPs were not signed by the resident's or the resident's legal representative.
Plan of Correction:	No residents were adversely affected by the deficient practice. The Individualized Service Plan for resident #1 and resident #7 were signed immediately. The Individualized Service Plans will be presented to the resident and a signature will be obtained upon the completion of the review. In the event the resident is unable to acknowledge the review of the ISP, a resident representative will be requested to acknowledge. In the event a resident representative is unable to be present, a copy of the resident?s ISP will be emailed to them for written acknowledgement. Unit Manager or designee will conduct a monthly audit for 3 months to ensure the Individualized Service Plans are signed and dated by the resident and/or resident representative. Any variances identified will be corrected, staff counseled and reeducated as appropriate. The results of the audit will be tracked and trended and presented to the campus wide QAPI committee.
Standard #:	22VAC40-73-550-G
Description:	Based on record review and interview, the facility failed to ensure the rights and responsibilities of residents in assisted living facilities were reviewed annually with each staff person. Evidence of this review shall be the staff person's written acknowledgment of having been so informed, which includes the date of the review, and should be filed in the staff person's record. Evidence: 1. During review of staff records with staff #7, staff #5 and staff #6 did not have a current annual review of the resident's rights and responsibilities in the record, and did not have a copy of the last resident's rights review conducted. 2. During interview, staff #2 and staff #7 acknowledged the aforementioned staff did not have a current resident's rights review in the record.
Plan of Correction:	No residents were adversely affected by the deficient practice. Resident rights and responsibilities have been reviewed with staff #5, #6 and #7. A complete audit of personnel records to assure that the staff receive annual review of resident rights and responsibilities has been conducted. The content of resident rights and responsibilities in assisted living facilities will be added to the annual schedule in the electronic Relias training software and assigned to each staff person. Unit Manager or designee will run monthly completion report for 3 months. Any variances identified will be corrected, staff counseled and reeducated as appropriate. The results of the audit will be tracked and trended and presented to the campus wide QAPI committee.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and interview, the facility failed to ensure the physician or other prescriber's orders, both written and oral, for administration of all prescription and over-the-counter medications identify the diagnosis for each drug. Evidence: 1. Resident #12's physician's order dated 5-1-19 was missing the diagnosis for Sinemet 25mg- 100mg tab. 2. Resident #13's physician's order dated 7-29-19 was missing the diagnosis for Gabapentin 300mg tab. 3. During interview, staff #2 acknowledged the missing diagnosis on the physician's orders for resident #12 and #13.
Plan of Correction:	No residents were adversely affected by the deficient practice. Diagnoses for resident #12?s orders for Sinemet and resident #13?s order for Gabapentin were added. A complete audit of all medications has been completed to ensure the diagnosis is linked to the physician?s order for each medication. Variances identified were corrected immediately. Unit Manager or designee will audit 50% of all new orders for 3 months to ensure each order contains a proper diagnosis. Any variances identified will be corrected, staff counseled and reeducated as appropriate. The results of the audit will be tracked and trended and presented to the campus wide QAPI committee.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview, the facility failed to ensure the interior of the building was maintained in good repair and kept clean. Evidence: 1. During a tour of the facility with staff #1, in room 308 the carpet had a brown stain in front of the bathroom. A corner of the wall facing the bathroom on the left side was cracked approximately one foot in length and missing a section of the wall, exposing the metal underneath. 2. In room 401 the beige carpet was discolored and had 3 black spots in front of the couch with several smaller black spots. The beige carpet was also discolored with dark spots in front of the sink in the kitchenette. 3. Staff #1 acknowledged the areas mentioned during the tour.
Plan of Correction:	No residents were adversely affected by the deficient practice. Carpet in room 308 and room 401 was cleaned. A wall facing the bathroom in room 308 has been repaired. All rooms identified to have recurring carpet stains have been put on a cleaning schedule. The Unit Manager or designee will conduct weekly inspections for one month to ensure carpet is clean and sanitary and walls are in good repair. Any findings identified will be corrected. The results of inspections will be tracked and presented to the campus wide QAPI committee.