VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Morningside of Charlottesville
491 Crestwood Drive
Charlottesville, VA 22903
(434) 971-8889

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: June 2, 2020 and June 3, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

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 6/2/2020 and concluded on 6/3/2020. The facility's administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census is 53. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four (4) resident records, four (4) staff records, health care oversight, medication administration records, physician orders, staff schedules, fire and health inspection reports, etc. submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were 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 and return to the Inspector within 10 days. 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 non-compliance with the standard, 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). All new personnel records were reviewed since the last inspection for criminal history record reports and all were in compliance.

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on a desk review for four residents, the facility failed to document that the order of priority for approval of placement of two individuals in a secure environment was followed. Evidence: A desk review of file documentation for residents # 2 and # 3 provided by the facility were signed by an adult child. The forms did document why approval was not secured from the resident (#1 on the list of priority). The forms did not document why approval was not secured from a guardian or other legal representative for the resident if one has been appointed (# 2 on the list of priority), or the spouse (# 3 on the list of priority).
Plan of Correction:	1. Steps to correct the noncompliance with the standards 22VAC40-73 (A) 1100.A Residents # 2 and # 3 records were updated and completed on the date of the inspection 2. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: The facility BTR Director, Sales and Marketing Director, and Director of Resident Care shall be reeducated by the ED (executive director) on the order of priority specifically subsection 3 to read as follows, A relative who is willing and able to take responsibility to act as the resident's representative, in the following specified order: (i)spouse, (ii) adult child, (iii) parent, (iv) adult sibling, (v)adult grandchild, (vi) adult niece or nephew, (vii) aunt or uncle. Th BTR Director/designee will complete an audit of current BTR resident files to ensure compliance with the order of priority. 3. Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: The facility BTR Director and/or authorized designee shall ensure all new admissions to the BTR shall have this form completed with appropriate order of priority as noted above to remain within compliance of this standard.
Standard #:	22VAC40-73-260-A
Description:	Based on a desk review for four staff on 6/2/2020 and 6/3/2020, the facility failed to ensure that each direct care staff member maintain current certification in first aid, Evidence:Documentation that staff # 2, # 3 and # 4 maintained current first aid certification was not provided during the desk review.
Plan of Correction:	1. Steps to correct the noncompliance with the standards 22VAC40-73(A) 260.A Business Office Manager and Director of Resident Care (DRC) and/or authorized designee shall coordinate with employee # 2 to schedule first aid and CPR class. Staff members # 3 and # 4 were provided to licensing inspector during remote survey via email. 2. Measures/systematic changes put in place to ensure that the deficient practice does not reoccur: The BOM (Business Office Manager)/designee will complete an audit of current all direct care staff to ensure all have current first aid and CPR training documentation in their file. DRC (Director of Resident Care) and or authorized designee shall annually, upon time of associate evaluation create a checklist to include CPR/FA certification checks for all direct care members. These credentials shall be retained in personnel fileat the physical location and updated as needed to remain in compliance with this standard. 3. (Person(s) responsible for implementing each step and/or Monitoring of corrective action to ensure the deficient practice will not reoccur: The Executive Director, DRC (Director of Resident Care) and BOM (Business Office Manager) and/or authorized designee will ensure initial compilation of class for associate # 2 ; thereafter, the BOM, DRC and/or authorized designee shall be responsible for maintaining all direct care personnel records for staff employed at Morningside of Charlottesville to remain in compliance with this standard.