VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cana Adult Home
2004 Wards Gap Road
Cana, VA 24317
(276) 755-4338

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Feb. 26, 2020

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 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 LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

The LI for Cana Adult Home, along with an additional LI, conducted an unannounced renewal study on 02/26/2020 from 9:30AM until 2:00PM, finding 20 residents in care. The inspection included a tour of the physical plant, observation of a medication pass, review of the medication storage carts, staff/resident interviews, and observation of portions of the midday meal and craft activity. Six resident records were thoroughly reviewed, and an additional four were partially reviewed in relation to the observation of the medication pass and/or special diets. Sworn disclosure statements and criminal record checks were examined for all newly hired staff, and the records of three staff were thoroughly examined. Additional facility documentation was surveyed for compliance with the Standards for Assisted Living Facilities. Findings were reviewed with facility staff during the inspection. An exit interview was conducted with the Administrator on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector 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, contact your licensing inspector at (540) 309-5982.

Violations:

Standard #:	22VAC40-73-120-A
Description:	120-A Based on review of staff records, the facility failed to give a new staff person orientation training that included requirements in 120-B within the first seven days of employment, and one required section of the orientation was missing. EVIDENCE: 1. Staff 1 was hired on 12/23/2019, and the new staff orientation was done on 1/3/2020. The orientation did not include section 120-B-2: the facility?s organizational structure.
Plan of Correction:	Facility will use current model form.
Standard #:	22VAC40-73-320-A
Description:	320-A Based on review of resident records, the facility failed to obtain some of the required information on a pre-admission physical for a resident. EVIDENCE: 1. The physical exam for resident 4 shows this resident showed allergies to NSAIDs and SULFA; however, the resident?s reactions to these were not shown.
Plan of Correction:	Facility will insure necessary information is in the physical prior to admission.
Standard #:	22VAC40-73-380-A
Description:	380-A Based on review of resident records, the facility failed to obtain some of the required resident personal and social information. EVIDENCE: 1. The ?Resident Personal & Social Data? form for resident 4 was lacking sections or the information was not obtained for the following sections: 2) Last home address, and address from which resident was received, if different; 5) Birthplace, if known; 7) Name, address and telephone number of all legal representatives, if any; 8) If there is a legal representative, copies of the legal documents; 10) Name, address, and telephone number of designated contact person authorized by the resident or legal representative, if appropriate, for notification purposes, including emergency notification and notification of the need for mental health, intellectual disability, substance abuse or behavioral disorder services ? of the resident or legal representative is willing to designate an authorized contact person; 11) Name, address, and telephone number of the responsible individual stipulated in 22 VAC 40-73-550-H, if needed; 14) Name, address, and telephone number of clergyman and place of worship, if applicable; 15) Address of the local department of social services; 17) Lifetime vocation, career, or primary role; 19) Known allergies, if any; 20) Strengths and problems associated with current behavioral and social functioning.
Plan of Correction:	Facility will use current model form.
Standard #:	22VAC40-73-450-A
Description:	450-A Based on review of resident records, the facility failed to complete a preliminary plan of care on or within seven (7) days prior to the date of admission. The standards allow this to be omitted if a comprehensive individualized service plan is done on the day of admission. EVIDENCE: 1. Resident 4 was admitted on 9/5/2019 and there is no preliminary plan of care. The comprehensive ISP was done on 9/6/2019.
Plan of Correction:	Facility will make sure ISPs will be completed prior to admission.
Standard #:	22VAC40-73-450-F
Description:	450-F Based on review of resident records, the facility failed to update individualized service plans (ISP) when resident needs changed. EVIDENCE: 1. The fall risk rating, dated 1/4/2020, for resident 4 shows this person is at medium risk of falling, and this is not addressed on the ISP, dated 9/6/2019. 2. The uniform assessment instrument (UAI), dated 6/5/2019, for resident 5 showed this resident had judgement problems, and this was not addressed on the ISP, dated 6/11/2019. 3. A fall risk rating, dated 1/7/2020, for resident 6 showed this resident is a high fall risk, and this was not addressed on the ISP, dated 9/19/2019. 4. The UAI, dated 9/16/2019, for resident 6 showed this resident had judgement problems, and this was not addressed on the ISP, dated 9/19/2019.
Plan of Correction:	Facility will make sure ISP contains all necessary information.
Standard #:	22VAC40-73-560-I
Description:	560-I Based on record review and staff interview, the facility failed to ensure that resident records contained a current photo. EVIDENCE: 1. The records for residents 1, 2, 3, 4, 5, and 6 lacked photographs. 2. Staff 4 stated that she had taken resident photos, but they were still on her phone and have not been printed or added to the resident records.
Plan of Correction:	Facility will make sure photographs will be placed in resident files.
Standard #:	22VAC40-73-680-K
Description:	680-K Based on document review, the facility failed to obtain a specific order for an as needed (PRN) medication. EVIDENCE: 1. The physician order for resident 10 stated to administer Tylenol 325mg 1-2 po q 6 hours prn pain/fever as directed [one to two tablets by mouth every six hours as needed for pain/fever as directed]. The standards require that the exact number of tablets be specified.
Plan of Correction:	Facility will obtain orders from physician stating exact dosage to be given.