VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at South Boston
435 Hamilton Boulevard
South boston, VA 24592
(434) 575-5400

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Dec. 6, 2019

Complaint Related: Yes

Areas Reviewed:

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

Comments:

The Piedmont Licensing Office received a complaint in regards to Commonwealth Senior Living at South Boston. The complaint alleges that the facility is keeping residents that are not assisted living level of care, and that wound care needs at not being met. The LI for Commonwealth Senior Living at South Boston conducted an unannounced complaint investigation at the facility on 12-6-2019 from 10am until 2pm in conjunction with 2 other LI's. Resident and staff records was well as other forms of facility documentation were reviewed and interviews were conducted with residents and staff. Based on the preponderance of evidence available for review this complaint is not valid. Other violation were noted and cited during this inspection. Please respond back to your LI with a plan of correction. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-220-A
Complaint related:	No
Description:	Based on a reivew of resident and private duty staff records, the facility failed to monitor the direct care and companion services to the resident by private duty personnel. EVIDENCE: 1. The record for private duty staff person 1 does not contain a qualifying certificate and/or license that the private duty staff is certified/licensed to provide direct care to resident 2. Interview with staff persons 1 and 2 reveled that staff is providing services to resident 2. The ISP for resident 2, dated 11/07/2019, shows that the private duty staff is providing grooming, toileting, dressing, transfers, ambulation, bathing and all personal hygiene. The Record for resident 2 does not include any documentation that the facility is monitoring the private duty services that are being provided to the resident.
Plan of Correction:	Required documentation was obtained to keep on 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. ISPs were updated and the records of other residents were reviewed to ensure compliance. Executive Director or designee will review this information monthly to ensure that the required information is up to date for continued compliance.
Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to ensure that the Uniform Assessment Instruments (UAIs) were completed as required. EVIDENCE: 1. The UAI for resident 2, dated 10/23/2019, shows RESIDENT 2 needs help with eating/feeding but does not include what type of help. The UAI also does not have a date that is was signed by the assessor and executive director.
Plan of Correction:	UAI for Resident #2 was updated to include type of assistance needed and the required signatures were obtained. At the time of admission, annually, and when there is a change in condition the Resident Care Director or designee will complete the UAI. UAI?s will be reflective of all identified needs of the resident to ensure the basic needs of the resident are adequately identified to protect the resident?s health and safety. Executive Director, Resident Care Director, and/or designee reviewed other UAIs to ensure compliance. Executive Director will complete random monthly audit of a minimum of 5 resident?s UAI to ensure ongoing compliance.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were assessed on residents individualized service plans (ISPs). EVIDENCE: 1. The UAI for resident 2, dated 10/23/2019, shows toileting is performed by others; however, the ISP shows that resident 2 needs mechanical/one person assist/ sitter does. Interview with staff revealed that resident 2 was assessed correctly as toileting is performed by others on the UAI dated 10/23/2019. 2. The record for Resident 4 contains documentation to show that the resident is receiving wound care services with a home health agency. The ISP for Resident 4, dated 10/9/2019, does not reflect the assessed need for wound care services. 3. The record for Resident 3 contains documentation to show that the resident is receiving wound care. The ISP for Resident 3, dated 10/07/2019, does not reflect the assessed need of wound care services.
Plan of Correction:	The comprehensive ISP for resident #2, 3, and 4 were updated. An audit of resident files was completed to ensure that comprehensive ISP was completed for all residents to ensure compliance. When a resident requires any assistance in care the resident would be considered dependent of care. Community will always encourage a resident dependent in care to perform tasks within that care need to their fullest capability. When a resident requires any assistance in care the resident would be considered dependent of care. Community will always encourage a resident dependent in care to perform tasks within that care need to their fullest capability. The ISP will continue to be specific in detailing care needs and tasks for care givers to ensure the residents care and services are provided to the resident?s choice and specifics. The RCD or designee will maintain ISP by updating services as needs change and goals are met with an audit by the ED, RCD, or designee auditing a minimum of 5 resident clinical records per month to ensure continued compliance.
Standard #:	22VAC40-73-480-C
Complaint related:	No
Description:	Based on a review of resident records, the facility failed to arrange for specialized rehabilitative services by qualified personnel as needed by the resident. EVIDENCE: 1. The record for resident 3 contained a physician?s referral, dated 9/11/2019, to utilize Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST). Resident 3's record contained no documentation to indicate the utilization of OT and ST services, and interview with staff person 1 confirmed OT and ST services had not been arranged per physician?s orders.
Plan of Correction:	Resident #3 was admitted with orders for PT, OT, and ST. Orders and treatment records were obtained and placed in the resident?s chart. All other charts were reviewed to ensure compliance. Resident Care Director or designee will meet with 3rd party providers post treatment to obtain the required documents and care changes. Executive Director or designee will review a minimum of 5 charts per month to ensure ongoing compliance.
Standard #:	22VAC40-73-650-E
Complaint related:	No
Description:	Based on review of resident records, the facility failed to ensure that physician orders were maintained in resident records. EVIDENCE: 1. The record for Resident 3 has documentation that the resident is receiving skilled nursing for wound care but did not contain a physician?s order for these services.
Plan of Correction:	The misfiled order was appropriately filed in the correct section of the resident?s chart. All other records were checked to ensure compliance. Executive Director or designee will audit a minimum of 5 charts monthly to ensure there is a physician order in chronological order in the residents file for every medication order on the Medication Administration Record.