VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LlVING AT CHURCHLAND HOUSE
4916 West Norfolk Road
Portsmouth, VA 23703
(757) 483-1780

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Dec. 18, 2019 and Dec. 19, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An unannounced renewal inspection was conducted by the Licensing Inspector from the Eastern Regional office on December 18, 2019 from 9:17 am until 4:05 pm and on December 19, 2019 from 9:37 am until 4:04 pm. There were 61 residents in care on both days. During the inspection, a tour of the building and grounds was conducted, a medication observation was conducted, and a review of the medication cart. Activities were observed to include a holiday movie and balloon tennis. The lunch menus was served as posted. Resident and staff records were reviewed. Criminal background checks were also reviewed for all new staff since the last annual inspection. There was a discussion regarding quantity of emergency water supply, carpets in hallway, ensuring documents are reviewed for completion and accuracy, snack descriptions on menu, the Health Care Oversight report, and admission physical exam information. The facility received violations in the areas of Personnel, Resident Care and Related Services, and Emergency Preparedness. The areas of non-compliance were reviewed with the Executive Director throughout the inspection and during the exit interview. 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 has been or will be corrected. Your plan of correction should include: 1. Step(s) to correct the non-compliance with the standard(s) 2. Measures to prevent re-occurrence; and 3. Person(s) responsible for implementing each step and/or monitoring any preventive action(s).

Violations:

Standard #:	22VAC40-73-220-A
Description:	Based on record review and interview, the facility failed to ensure prior to initiation of companion services with private duty personnel from a licensed home care organization, the facility obtained in writing information on the type and frequency of the services to be delivered, and failed to ensure that orientation and training was provided to private duty personnel on the facility's policies and procedures related to their duties. Evidence: 1. Resident #7's nursing notes documented the resident had a private duty sitter provided by a licensed home care organization. 2. Staff #2 stated resident #7's private duty sitter provides 1:1 supervision to the resident at all times at the facility, after the resident returns from the Adult Day Care Center. Staff #2 stated that the private duty sitter services started approximately in October, after the resident's safety helmet was discontinued by the physician on 10-10-19. 3. Staff #1 and staff #2 were unable to provide documentation that private duty sitter #1 received training and orientation on the duties of private duty sitters at the facility, and documentation in writing of the type and frequency of services to be provided prior to the initiation of services. Per staff #1 the documentation for private duty sitter #1 was misplaced.
Plan of Correction:	Required documentation was obtained to keep in file in the community. Business Office Manager or designee will ensure that all required information is on file for any private duty aide who works for an outside licensed home care agency. Executive Director or designee will review this information monthly to ensure that the required information is up to date for continued compliance.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) include a description of the resident's identified needs. Evidence: 1. On 12-18-19, during review of resident #1's record, the record contained a letter from the court dated 4-6-18, documenting the resident had a court appointed Guardian. However, the resident's comprehensive ISP dated 9-11-19 did not document the resident's need for a Guardian. 2. On 12-19-19, review of resident #6's comprehensive ISP dated 12-10-19 documented the resident needs mechanical assistance with bathing, dressing, and toileting; however, the ISP did not indicated the mechanical devices needed. 3. Resident #7's record documented in the nursing notes that the resident has a private duty sitter. The resident's ISP dated 9-30-19 did not reflect the resident's need for a private duty sitter, the services provided by the sitter, and the frequency of services.
Plan of Correction:	ISP for Resident #1, 6, and 7 was updated to include identified need and what type of assistance staff are to provide to include coordinated services and basic needs identified. Community will continue to complete Preliminary and Comprehensive ISPs in conjunction with resident, family, and or caregivers to ensure the basic needs of the resident are adequately identified to protect the resident's health, safety, type of assistance required by coordinated services if applicable, and signature of legal representative. Executive Director, Resident Care Director, and/or designee reviewed other ISPs to ensure compliance. Executive Director will complete random monthly audit of 5 ISPs to ensure ongoing compliance.
Standard #:	22VAC40-73-580-D
Description:	Based on record review and interview, the facility failed to ensure if a resident has been assessed on the Uniform Assessment Instrument (UAI) as dependent in eating/feeding, the Individualized Service Plan (ISP) shall indicate an approximate amount of time needed for meals to ensure needs are met. Evidence: 1. Resident #3 was assessed on the Uniform Assessment Instrument (UAI) dated 10-8-19 as needing assistance with feeding, to include spoon feeding. The ISP dated 10-11-19, documented the resident needs assistance with feeding, however it did not indicate the approximate amount of time needed for meals to ensure needs are met. 2. Resident #7 was assessed on the UAI dated 9-27-19 as needing assistance with feeding. The ISP dated 9-30-19 documented that the resident is dependent on direct care staff to spoon feed every meal. However; the ISP did not indicate the amount of time needed for meals to ensure his needs are met. 3. During interview, staff #1 and staff #2 acknowledged residents #3 and #7 need assistance with feeding and the amount of time need to complete meals was not documented on the ISP.
Plan of Correction:	ISP for Resident #3 and 7 was updated to include approximate amount of time that the resident takes to consume a meal. All other resident ISPs were reviewed to ensure compliance. Executive Director, Resident Care Director, and/or designee reviewed other ISPs to ensure compliance. Executive Director will complete random monthly audit of 5 ISPs to ensure ongoing compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on observation and interview, the facility failed to implement methods to prevent the use of outdated medications as written in its medication management plan. Evidence: 1. On 12-18-19 during a review of the "AL North" medication cart with staff #5, the following outdated medications were observed: a. One (1) bottle of Polyethylene Glycol powder 17gm, expired 5-2019; and b. Loperamide Hydrochloride, expired 1-2019. 2. Staff #5 stated the Polyethylene Glycol powder belonged to resident #3 and the Loperamide Hydrochloride belonged to resident #9. Staff #5 acknowledged the aforementioned medications had expired. 3. The facility's Medication Management Policy and Procedure for "Outdated, Damaged, or Contaminated Medications" documented that outdated, damaged, or contaminated medications will not be "retained in the Community", "Med Aides are responsible for identifying outdated, damaged, or contaminated medications", and the "Resident Care Director will regularly inspect containers for outdated, damaged, or contaminated medications".
Plan of Correction:	All nurses and RMAs re-educated on the medication management policy and to specifically dispose of any expired medications and do not administer. Executive Director, Resident Care Director, or designee will ensure adherence to the medication management policy with training at time of hire, annually and as needed. Resident Care Director or designee will observe a medication pass weekly to include each shift within the month to ensure continued compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and record review, the facility failed to ensure medications were administered in accordance with the physician's or other prescriber's instructions. Evidence: 1. On 12-18-19 during the morning medication pass observation, staff #5 administered Quetiapine 25mg, Hydralizine 50mg, Aripiprazole 2mg, and Setraline 50mg whole tabs to resident #2 in a pill cup. The resident was observed unable to get all of the medications out of the cup, as two (2) pills were stuck to the bottom of the cup. Staff #5 obtained a spoon, scooped out the remaining two (2) pills and administered them to resident #2. 2. Resident #2's physician's order dated 9-20-19 documented, "medications to be crushed and administered in applesauce/pudding/or yogurt unless contraindicated". Only the Aripiprazole 2mg indicated "do not crush", all other medications administered were not crushed as per the physician's instructions. 3. Resident's Individualized Service Plan (ISP) dated 8-15-2019 and physician's orders dated 9-20-19 documented the resident is on a mechanical soft consistency diet.
Plan of Correction:	Resident Care Director will re-educate all RMAs and Nurses on adherence to the Rights of Medication Administration to include medications being administered in accordance with the physician orders and Board of Nursing Standard of Practice. Resident Care Director or designee will conduct a random medication pass audit a minimum of 2 times per month to ensure ongoing compliance and provide any necessary coaching on medication administration concerns.
Standard #:	22VAC40-73-980-H
Description:	Based on observation and interview, the facility failed to ensure at least 48 hours of the 96-hour supply of emergency drinking water was maintained on site. Evidence: 1. On 12-18-19 during a review of the emergency water supply with staff #4, the facility had 11 boxes containing six (6) packs of one (1) gallon water bottles, totaling 66 gallons of emergency drinking water. 2. Staff #1 stated there were 61 residents in care. 3. The required amount of emergency drinking water to be on site for 61 residents for 48 hours is 122 gallons. 4. Staff #4 acknowledged the facility did not have a 48 hour supply of emergency drinking water on site.
Plan of Correction:	The additional water was ordered and delivered to the community to ensure the DSS required amounts were on hand at the community. Dining Services Director or designee will ensure that community will have required emergency food and water supply on site and will check monthly for continued compliance. Executive Director will audit by the 25th of every month to ensure continued compliance.