VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LIVING AT HAMPTON
1030 TOPPING LANE
Hampton, VA 23666
(757) 826-3728

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: April 22, 2020 and April 23, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on April 21, 2020 and concluded on April 23, 2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 83. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 5 resident records, 5 staff records, healthcare oversight, health inspection report, fire inspection report, April staff work schedules, nutrition oversight of special diets, fire and emergency evacuation drills, staff practice elopement drills, new staff criminal record checks and sworn disclosures. The following topics were discussed: Ensure Individualized Service Plan template is compliant with the Standards for Licensed Assisted Living Facilities; Healthcare oversight requirements, Special Care Unit administrator justification, and Physical Examination Reports. Information gathered during the inspection determined non-compliance(s) with an applicable standard or law, and a violation was documented on the violation notice issued to the facility. Please complete the ?plan of correction? and ?date to be corrected? for the violation cited on the violation notice. The plan of correction should indicate how the violation will be or was corrected. Your plan of correction should include 1. Step(s) to correct the noncompliance with the standard; 2. Measures/methods to prevent reoccurrence; and 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. The plan of correction is due within 10 calendar days.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the comprehensive individualized service plan (ISP) included a written description of what services were provided to address the residents? identified needs, and other services and who will provide them. Evidence: 1. Resident #1?s ISP dated 02-28-20 did not include hospice services. The resident?s record contained a physician?s order (dated 12-10-2018) to initiate hospice services. 2. Resident #2?s ISP dated 03-12-20 did not include bowel or bladder needs. The resident?s Uniform Assessment Instrument (UAI) dated 03-05-20 documented the resident is incontinent of bowel and bladder weekly or more and requires assistance. 3. Resident #4?s ISP dated 02-28-20 did not include dressing needs. The resident?s UAI (dated 02-03-20) documented the resident requires mechanical help with dressing. 4. Resident #5?s ISP dated 04-06-20 did not include bowel needs. The resident?s UAI (dated 4-6-20) documented the resident is incontinent of bowel weekly or more and requires assistance.
Plan of Correction:	What has been done to correct? Resident #1, 2, 4, and 5s ISP was updated to reflect residents' current needs. How Will Recurrence Be Prevented? Resident Care Director will ensure that each ISP is reviewed and updated annually or if there is a change in the residents' condition. ISPs will continue to be reviewed to ensure compliance. Records will be reviewed to include identified needs and what type of assistance staff are to provide to include: coordinated services, basic needs, and mechanical assistance/help. ISPs will be reviewed by Executive Director after each care-plan meeting. Person Responsible: ED, AED, RCD, ARCD, and or Designee.