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: Sept. 25, 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

Technical Assistance:

TA: DNR documentation on the ISP should address the facility?s plan for facility staff should a resident become unresponsive. The use of hand soap in resident's rooms in the safe, secure environment should be based on the resident's ability to use the soap properly and the population on the unit at the time. Hand soap is an infection control measure and should not be inaccessible to the resident if there is no risk of a resident ingesting it.

Comments:

On 09/25/2019 two VDSS inspectors were on site to conduct the renewal inspection. The Licensing Administrator for the Central region and a VDSS Home Office representative were also present for the renewal inspection. The VDSS representatives reviewed residents and staff records as well as other facility documents for compliance. Observation of a medication administration pass, a tour of the facility?s physical plant, and interviews with residents, family members, and staff were conducted. 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 8:30 a.m and 5:45 p.m.

Violations:

Standard #:	22VAC40-73-1110-A
Description:	Based on the review of facility records and interviews conducted with the facility?s Administrator on 09/25/2019, the facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, that the licensee, administrator, or designee determined whether placement in the special care unit is appropriate. The determination and justification for the decision shall be in writing and shall be retained in the resident's file. Evidence: Resident #1 (admitted 02/26/18) and #2 (admitted 02/26/18) Upon request the facility, did not provide written documentation that the determination and justification for the decision that placement of resident #1 and #2 on the facility?s safe and secure environment was appropriate when transferred to the safe, secure environment from the assisted living side. The facility administrator was provided the opportunity to locate this documentation in the residents? records and could not locate it.
Plan of Correction:	Memory Care DON will review files for residents residing in the secured memory care units to ensure documentation is present in their files to support placement in a secured environment. FACILITY RESPONSE- "Memory Care DON and ED to review files of current residents and any new admissions prior to move in".
Standard #:	22VAC40-73-220-A
Description:	Based on a review of resident records and interviews conducted with the facility Administrator on 09/25/2019, the facility failed to ensure that the direct care or companion services provided by private duty personnel to meet identified needs were reflected on the resident?s individualized service plan. EVIDENCE: RESIDENT #1 (admitted 02/26/18) The facility?s Administrator stated during interviews conducted on 09/25/2019 that the resident has a private sitter. The resident?s most recent ISP dated 04/25/2019 that was submitted for the inspector?s review did not contain documentation reflecting services to be provided by, or the identified need being met, by the private duty personnel.
Plan of Correction:	FACILITY RESPONSE- "Any resident receiving services provided by private duty sitter will have services documented on their ISP. Directors of Nursing to review ISPs at least annually and as needed for updates. ED to monitor on a monthly basis and as needed."
Standard #:	22VAC40-73-410-A
Description:	Based on a review of resident records, the facility failed to provide, upon admission, an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system modified as appropriate for residents with cognitive impairments with a signed and dated acknowledgment of having received the orientation by the resident and, as appropriate, his legal representative. Evidence: Resident #8 (admitted 05/27/19) The Nursing Resident Orientation form which includes explanation of pull cord/call bell operation and emergency response, fire plan and fire exits, etc was in the resident record but was not signed their legal representative. A handwritten note reading ?Due to cognitive status resident could not repeat to staff.?
Plan of Correction:	FACILITY RESPONSE- "Documentation of new resident orientation will be completed and appropriate signatures based on resident?s level of cognition will be obtained. Admission Director, Directors of Nursing and ED to review new admission files to ensure compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to include on the comprehensive Individualized Service Plan (ISP) a description of identified needs and date identified based upon the fall risk rating including a written description of what services will be provided to address identified needs, when and where the services will be provided, or the expected outcome and time frame for expected outcome. EVIDENCE: Resident #8 The Fall Risk Assessment dated 08/26/2019 indicated the resident scored a 21. The score of 10 or higher indicates a high fall risk as indicated on the Fall Risk Assessment. The comprehensive ISP contained documentation dated 08/26/2019 addressing a fall on the same date but not the identified need pertaining to fall risk, a description of need, or a goal date.
Plan of Correction:	FACILITY RESPONSE- "Directors of Nursing will review ISPs to ensure Fall Risk is addressed on ISP timely and includes description of need and goal date. Directors of Nursing and ED to review a minimum of 8 charts per month for 3 months and then monitor for necessary updates as needed.
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and interviews conducted with the facility?s Administrator on 09/25/2019, the facility failed to update a resident?s Individualized Service Plan (ISP) as needed as the condition of the resident changed. EVIDENCE: RESIDENT #1 (admitted 02/26/18) The review of facility records revealed the following: Facility records noted that the resident was transferred to the safe, secure environment from the assisted living side. The resident?s most recent ISP dated 04/25/2019 ISP was not updated to reflect a safe, secure environment as an identified need when the resident transferred to that area of the building. Resident #2 (admitted 02/26/18) Facility records that were submitted for the inspectors review noted that the resident was transferred to the safe, secure environment on 07/25/2019. The resident?s most recent ISP dated 04/25/2019 was not updated to reflect a safe, secure environment as an identified need when the resident transferred to that area of the building. Resident #7 (admitted 05/18/2018) Facility records that were submitted for the inspector?s review noted that the resident was transferred to the safe, secure environment with a lease effective date of 04/01/2019. A licensing representative asked the Administrator of the exact date of transfer and she was unsure as she was not employed by the facility at the time of transfer. The resident?s most recent ISP was updated on 5/26/19 and 8/25/19 and did not reflect a safe, secure environment was an identified need when the resident transferred to that area of the building.
Plan of Correction:	FResidents requiring a secured memory care neighborhood will have documentation of this need reflected on their ISP. MC resident charts will be reviewed and ISPs updated by Memory Care DON. Director of Nursing and ED to review a minimum of 8 charts per month for 3 months and then monitor for necessary updates as needed. ACILITY RESPONSE- "
Standard #:	22VAC40-73-640-A
Description:	Based on the review of facility records and interviews conducted with the facility?s Administrator on 09/25/2019, the facility failed to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: Resident #4 ? Facility records that were submitted for the inspectors review noted that the resident was prescribed Clopidogrel 75mg tablet (Plavix) Take one tablet by mouth every evening at bedtime for AFIB. Facility staff documented on August 19, 2019 at the 9:00pm dosing schedule on the August 2019 Medication Administration Record (MAR) ?Other: Out?. Facility staff confirmed that the notation ?Out? meant that the medication was not on-site at the facility to administer to the resident and the resident was not administered the medication. ? Facility records that were submitted for the inspectors review noted that the resident was prescribed Clopidogrel 75mg tablet (Plavix) Take one tablet by mouth every evening at bedtime for AFIB and Atorvastin 20 MG Take one tablet by mouth at bedtime for cholesterol. Facility staff documented on September 6, 2019 at the 9:00p.m schedule on the September 2019 MAR ?MD MADE AWARE?. Facility staff confirmed that the notation ?MD MADE AWARE? meant that the medication was not on-site at the facility to administer to the resident and the resident was not administered the medication. ? The facility policy titled, ?Administration of Medications? revised March 5, 2019 states, ?Medication fills and refills shall be timely to avoid missed dosages. Medications should be reordered according to the pharmacy procedures or electronic record vendor procedures. If a medication that is ordered does not arrive as scheduled, the Director of Nursing or designee shall be notified so that the pharmacy can be contacted via telephone for a stat delivery or follow electronic record policy for checking status.? No documentation was at the facility indicating that any of these procedures were completed.
Plan of Correction:	FACILITY RESPONSE- "RMAs and LPNs received training from facility contracted pharmacy provider on proper procedures for reordering medications and requesting STAT orders to ensure all medications are available to be administered as ordered. Med Tech 4 Hour Refresher training & general pharmacy policy and procedure trainings held as well. Training dates: 10/8/19, 10/16/19, 10/17/19 & additional training date: 11/14/19 Directors of Nursing, Unit Coordinator and ED will monitor med passes daily to ensure medications are administered as ordered, ad and variations are reported to MD and documented accordingly."
Standard #:	22VAC40-73-660-A
Description:	Based on observation, the facility failed to use a medicine cabinet, container, or compartment for storage of medications and dietary supplements prescribed for residents when such medications and dietary supplements are administered by the facility that was locked. Evidence: As evidenced by the photographs taken, two licensing representatives observed several bottles of Ensure and Boost prescribed and labeled for specific residents in an unsecured refrigerator in the common area kitchen of the safe, secure environment accessible to residents.
Plan of Correction:	FACILITY RESPONSE- "All direct care staff on Memory Care units have been trained on properly locking refrigerators. Memory Care DON and Charge Nurse to monitor daily for compliance."
Standard #:	22VAC40-73-680-C
Description:	Based on a review of residents? records, the facility failed to ensure that medications were administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule EVIDENCE: The following medication doses were administered more than one hour after the standard dosing schedule based on documentation obtained during the inspection of residents? Med Delivery reports. Resident #1 August 2019 ? 12 doses September 2019 ? 19 doses Resident #2 August 2019 ? 13 doses September 2019 ? 24 doses Resident #7 August 2019 ? three doses September 2019 ? 10 doses Resident #8 August 2019 ? 17 doses September 2019 ? 31 doses Resident #9 August 2019 ? 38 doses September 2019 ? 27 doses Resident #10 August 2019 ? 20 doses September 2019 ? 10 doses
Plan of Correction:	FACIILTY RESPONSE- "RMAs and LPNs received training from facility contracted pharmacy provider on proper procedures for reordering medications and requesting STAT orders to ensure all medications are available to be administered as ordered. Med Tech 4 Hour Refresher training & general pharmacy policy and procedure trainings held as well. Training dates: 10/8/19, 10/16/19, 10/17/19 & additional training date: 11/14/19 Directors of Nursing, Unit Coordinator and ED will monitor med passes daily to ensure medications are administered as ordered, ad and variations are reported to MD and documented accordingly".
Standard #:	22VAC40-73-680-D
Description:	Based on a review of facility records and an observation of a 9am medication pass by two licensing representatives conducted at the facility on 09/25/2019, 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. EVIDENCE #1: The Med Delivery log for the following residents indicates a status of ?Missed? beside the medication doses as well as blank boxes corresponding to the same medication, date, and scheduled dosing schedule on the residents? Medication Administration Records: Resident #2 September 2019-one dose Resident #6 August 201-one dose Resident #8 August 2019-one dose Resident #10 August 2019-one dose. Evidence #2 Staff #6 administered all medications to resident #11. Upon returning to the medication cart the Staff #6 began preparing medications for another resident. A licensing representative asked the staff member if she signed off that she had administered the medication or if she signed off that she administered the medications prior to actually giving them. Staff #6 stated that she had already signed that the medications were administered prior to giving them to the resident. The staff member stated it was ?habit? and continued to prepare medications for the next resident. The staff member began documenting in the Medication Administration Record and stated, ?Getting ready to do it again. Habit? when preparing medications for another resident. EVIDENCE #3: Resident #9?s Medication Administration Record (MAR) indicated that the resident refused the following medication doses but no documentation indicating communication with the physician was in the resident record. A licensing representative asked the administrator why the physician was not called and she stated she did not know. August 2019: Uristat 95mg ? 72 out of 90 doses. Staff noted on 08/11/2019 that ?resident refused requested that dr discontinues? Citracal-Vit D 400-500 PET? 24 out of 26 doses Diclofenac Sodium 1% Gel ? 48 out of 124 doses Diltiazem 24hr ER 240mg Cap ? 18 out of 30 doses Famotidine 20mg tablet - 15 out of 60 doses Hydroxychloroquine 200mg tablet ? 21 out of 60 doses Potassium CL ER 10 MeQ cap - 49 out of 60 doses September 2019 (based on September 25, 2019 inspection date) Diclofenac Sodium 1% Gel ? 38 out of 98 doses Diltiazem 24hr ER 240mg Cap ? 17 out of 25 doses Potassium CL ER 10 MeQ cap - 46 out of 49 doses Uristat 95mg ? 71 out of 74 doses.
Plan of Correction:	FACILITY RESPONSE- "RMAs and LPNs received training from facility contracted pharmacy provider on proper procedures for reordering medications and requesting STAT orders to ensure all medications are available to be administered as ordered. Med Tech 4 Hour Refresher training & general pharmacy policy and procedure trainings held as well. Training dates: 10/8/19, 10/16/19, 10/17/19 & additional training date: 11/14/19 Directors of Nursing, Unit Coordinator and ED will monitor med passes daily to ensure medications are administered as ordered, ad and variations are reported to MD and documented accordingly."
Standard #:	22VAC40-73-930-D
Description:	Based on the review of facility records and interviews conducted with the facility?s Administrator on 09/25/2019, 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: Resident #1 resides on the safe secure environment. The resident?s ISP contains no information related to the inability to use the call bell system or how often staff needs to make rounds to monitor for emergencies and address unanticipated needs.
Plan of Correction:	FACILITY RESPONSE- "Residents identified as having an inability to use a call bell system will have this need documented on their ISP. Memory Care resident charts will be reviewed and ISPs updated as needed. Memory Care DON to review ISPs at least annually and as needed. Executive Director will monitor on a monthly basis and as needed".