VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Virginia Beach
937 Diamond Springs Road
Virginia beach, VA 23455
(757) 493-9535

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Jan. 9, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS

Comments:

An unannounced complaint inspection was conducted on January 9, 2020 from 1:00 p.m. to 2:50 p.m. regarding resident records not being provided to resident?s legal representatives, and rate changes not being appropriate for care received. There were 32 residents in care. The complaint is valid. The following was discussed: documenting what is sent in the resident?s record to responsible parties as requested. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures.

Violations:

Standard #:	22VAC40-73-380-A
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure copies of current legal documents that show proof of each legal representative?s authority to act on behalf of the resident and that specify the scope of the representative?s authority to make decisions and to perform other functions. Evidence: 1. Resident #1 admitted 07-31-15. The resident?s record reflected the resident had a guardian and conservator in place effective 07-14-15. 2. On 01-09-20 during record review, resident #1?s record did not contain copies of current legal documents to reflect a change in conservatorship that became effective 06-18-19. 3. Staff #1 acknowledged the change in conservatorship for resident #1, and that the change was not documented in the resident?s record.
Plan of Correction:	1. Legal documents of Resident#1 reviewed and updates requested from the guardian. 2. An audits of legal records will be conducted by the business office manager/executive director/designee to ensure a copy is stored in the residents? files. 3. In service re-training related to required legal documents and updates will be provided to the business office manager by the executive director. 4. Process will be reviewed by the executive director/designee monthly for 2 months with an audit of 10% of admissions monthly. Findings will be reviewed at the quality assurance meeting for continued implementation and analysis. Additional corrective action will be implemented by the executive director/designee based on the findings.
Standard #:	22VAC40-73-390-B
Complaint related:	Yes
Description:	Based on record review and interview, the facility failed to ensure updates of the signed agreement were provided to the resident and, as appropriate, his legal representative and retained in the resident?s record. Evidence: 1. Resident #1 admitted 07-31-15. Staff #1 stated that resident #1 had rate changes/increases. 2. Resident #1?s agreement 07-31-15 documented, ?We will provide thirty (30) days written notice of any change in the rates or pricing method for Basic Services, Personal Services, Select Services and Therapeutic Services?? 3. Requested staff #1 to provide documentation of notification of rate increases that were provided to resident #1?s responsible party. Staff #1 could not produce documentation and stated, ?A standard letter is sent to all residents? responsible parties notifying of rate changes.?
Plan of Correction:	1. Agreement of Resident#1 reviewed and updates provided to the guardian. 2. An audit of agreements will be conducted by the business office manager/executive director/designee to ensure the residents? records are up to date and communication provided to the resident representative(s). 3. In service re-training related to resident agreement, updates, and communication will be provided to the business office manager by the executive director. 4. Process will be reviewed by the executive director/designee monthly for 2 months with an audit of 10% of new admissions monthly. Findings will be reviewed at the quality assurance meeting for continued implementation and analysis. Additional corrective action will be implemented by the executive director/designee based on the findings.