VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Dunlop House
235 Dunlop Farms Boulevard
Colonial heights, VA 23834
(804) 520-0050

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Feb. 11, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS

Comments:

Responding to a 01/12/2020 complaint made against the facility regarding the facility?s policies and procedures; the inspector initiated an onsite inspection into the matter on 02/11/2020 between the approximate hours of 9:00 .m and 4:15 p.m. An entrance interview explaining the purpose of the investigation was conducted with the facility Administrator. While on site the inspector also conducted Interviews with facility staff and a regional representative. Based on facility documentation an observation of a resident?s room was also conducted. Some but not all facility records requested for review were submitted. Based on the information gathered during this complaint investigation it has been determined that the complaint made against the facility is valid. The noncompliance revealed during this investigation is contained within this report. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned it to me 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 please feel free to contact me at (804)-662-9774 or at Angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures. Evidence: Resident #1-Documentd date of admission 12/06/2019; Documented date of discharge 12/18/2019. The facility?s 3/2015 Memory Care Center Level-1 agreement dated 12/05/2019 by the resident?s POA notes in part on page 4 under the heading TERMINATION OF LEASE AGREEMENT section A: ?The first thirty (30) days of this Agreement are probationary so that the Facility can assess the ability of the Facility to provide the level of service required by the Resident. If the Resident?s needs cannot be met, then the Facility may terminate this Agreement within the first thirty (30) days. The TERMINATION OF LEASE AGREEMENT section B in part notes ?The notice of termination shall, to the extent practical, specify the needs of the Resident which are not able to be met by the Facility.? 12/18/2019: After twelve (12) days in care resident #1 was admitted to a local hospital from the facility. -12/23/2019: The complainant reported that facility staff #1 left him a voice message stating that ?her director had stated to her that they were going to be unable to accept the patient back?; upon discharge from the hospital. The complainant also reported that ?About a half-hour later facility staff #1 ?left another voice mail, stating that I should disregard the prior voicemail message, which I did.? -01/07/2020 the complainant alleges that he left a voicemail message for facility staff i#1 informing her that ?the patient was behaviorally stable and ready for placement and that facility staff #1 ?called me back and left a VM, stating that the facility was not going to be able to accept the patient back. ?(Facility staff #1 identified) did not ask to review or been sent supporting clinicals documenting the patient?s behavioral stability.? The complainant further alleged that he informed the resident?s POA; not the facility that upon discharge from the hospital, the resident could not return to the facility. Facility Service Notes document: Facility staff #1 documented on 01/07/2020 that she informed the resident?s daughter on 12/8/2019 that ?there was a strong possibility resident would not be able to return Dunlop House.? The facility?s Service Notes document that was submitted for the inspector?s review does not note an entry on 12/08/2019 that was written by facility staff #1. -01/08/2020: The complainant reported that he spoke with the facility?s (Director identified) and ?she purported to be unaware that the resident had been rejected for re-admission at the facility by (Facility staff #1 identified).? -During the interview the resident?s Power of Attorney (POA) stated that facility staff #1 did not tell her that the resident could not return to the facility and that she was not given or received a Notice of Termination from the facility. -02/27/2020: A facility Transfer/Discharge Statement document received at the department via an email from the facility notes under the heading Date of Discharge: 12/18/2019; destination- (local hospital is identified). Facility staff #2 documented on the same facility Transfer/Discharge Statement document that the resident?s POA was notified of the 12/18/2019 discharge on 1/15/2020; twenty-eight (28) days later. Upon request the facility did not submit for the inspector?s review documented evidence that prior to 12/18/2019 and during the resident?s hospitalization that the resident?s POA was given a Notice of Termination that identified the needs of the resident which are not able to be met by the facility.
Plan of Correction:	FACILITY RESPONSE- "1) Steps to correct non-compliance with the standard: The facility made the determination that the needs of the resident were unable to be met and sought to discharge the resident under the emergency discharge provisions. However the facility did not properly notify the resident's legal representative, designated contact person, family, caseworker, social worker, or any other persons, as appropriate, as rapidly as possible or by close of the day following discharge, the reasons for the move as stipulated. For all facility initiated discharges the resident?s legal representative, designated contact person, the family, caseworker, social worker, or other agency personal, as appropriate, shall be informed as rapidly as possible, but no later than by the close of the business day following discharge, of the reason for the move. The Administrative designee will note date and time of notification in residents record and a written statement containing the reasons for discharge and other required information will be provided within 14 days. 2) Measures to correct non-compliance from occurring again: The administrator/designee will monitor all facility initiated discharges and ensure the following: 1) Signing the written confirmation of transfer/discharge including date, person notified, person issuing, reasons for discharge, placement location, assistance provided, and administrator/designee signature, and 2) Initialing or countersigning the review of the documentation in the resident?s chart that details initial conversations with applicable persons regarding the facility initiated discharge. 3) Person responsible for implementing each step and/or monitoring any preventative measures: The administrator and/or designee will be responsible for implementing each step and/or monitoring the preventative measures.