VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Discovery Commons Virginia Beach
1628 Old Donation Parkway
Virginia beach, VA 23454
(757) 496-8001

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

Inspection Date: Oct. 23, 2019 and Oct. 24, 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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

An unannounced renewal inspection was conducted on 10-24-19(8a.m to 4:55p.m) and on 10-24-19(8:30a.m to 2:05p.m). There were 73 residents in care. Ten resident records and five staff records were reviewed . Interviews were conduced with staff, residents and collateral contacts. Two staff were observed administering medications. Observed the posted morning fitness activity and the afternoon bingo. Monthly a cooking demonstration in offered by the chef. The facility uses a four cycle menu. Emergency menus are available. The facility has a water contract . Each resident has four gallons of water in stored on the their closet. Staff check to ensure the supply in the resident closets is maintained and not expired. Nursing staff conduct cart audits twice monthly reconciling orders medication and the MAR . Staff also have medication reviews which includes test . All staff have to score at least 85% on all reviews. Please submit your plan of correction on or by November 7,2019.

Violations:

Standard #:	22VAC40-73-450-A
Description:	1. Based on record review and interview the facility failed to ensure one of nine preliminary individualized service plans reviewed include a written description of all services provided to adequately protect a resident's health, safety, and wellbeing . 2. During interview the inspector learned private duty sitter services (three to four hours Monday thru Friday) were in place at the time of resident #4's admission on 1-9-18 and continued to the present. . 3. Neither the preliminary ISP completed on the day of resident #4's admission nor the current ISP dated 10-17-19 listed the private duty services. .
Plan of Correction:	1. On 10/30/19 the ISP for #4 was reviewed by RRD and updated to assure it appropriately reflected this resident?s current needs including private duty services. 2. An audit of private duty services of current residents at the community will be completed by RSD and LGD or designee to assure that ISP?s accurately reflect the residents? needs. This audit is to be completed by 11/30/19. Any changes or updates necessary as a result of the audit will occur at time of review. 3. Training will be provided by the Divisional Director of Care to RSD, LGD, RSS, RRD and ED on completing accurate and timely ISPs. This training is to be completed by 11/15/19. 4. The RSD, RRD, and LGD or designee will assure that the assessed needs reflected on the ISP are accurate for new and current residents? per regulatory standards. Over the next 90 days, the ED will complete a thorough review of newly completed and/or updated ISPS to assure they accurately reflect that residents? current needs. Any updates or corrections that are needed as a result of that review will be addressed at time of review.
Standard #:	22VAC40-73-680-D
Description:	1. Based on observation, interview, and record review, the facility failed to ensure a resident?s medication were given as the physician instructed. 2. At 8:21a.m. the inspector observed staff #4 give resident #4 his Sodium Chloride 1gm tab(hyponatremia) and his Cefuroxine 500mg 1 tab(antibiotic) with a cup of water. 3. During interview staff #6 stated that it was confirmed by the resident that the medications were not given with food or a meal. 4. The inspector and staff #6 reviewed the physician order signed 10-4-19, indicating the Sodium Chloride 1gm tab twice daily (hyponatremia) was to be given with meals and the script dated 10-17-19 for the Cefuroxine 500mg 1tab 7 days twice daily (antibiotic) was to be given with food .
Plan of Correction:	The order for resident #4 for Sodium Chloride 1gm is getting clarified with physician by RSD by 11/8/19. Cefuroxine 500mg was short term medication which has since been completed. 2. The RSD will complete a review of orders to assure orders are accurate and appropriate. Any issues found will be corrected during this review. This review and appropriate follow-up will be completed by 11/15/19. 3. Training will be provided to medication staff on appropriate physician orders and following physician orders. This training will be completed with medication staff by 11/15/19 by the RSD. 4. The RSD is responsible for assuring medication is administered as ordered by MD to include appropriate documentation. For the next 60 days the RSD or designee will complete a daily review of the Medication Administration Records for residents currently on the medication program to assure medications have been administered as scheduled or appropriate documentation has occurred to meet regulatory standards. The Executive Director (ED) will be provided a report of findings weekly. Any compliance concerns found during review will be immediately addressed with the employee and appropriate action will be taken.