VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Huntington
11143 Warwick Boulevard
Newport news, VA 23601
(757) 223-0888

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: July 6, 2020 , July 7, 2020 , July 8, 2020 , July 14, 2020 and July 16, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION VAC40-73 ADMISSION, RETENTION, AND DISCHARGE 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

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 7-6-20, 7-7-20, 7-8-20, 7-14-20 and concluded on 7-16-20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 27. The inspector e-mailed the administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, physician's orders, staff schedule, healthcare oversight, health department inspection, fire and emergency drills, and new hire since last renewal inspection date, sworn statement/affirmation and criminal history record report. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-320-A
Description:	Based on record review and staff interview, the facility failed to ensure the physical examination report contained all of the required information for two of three residents. Evidence: 1. During the remote renewal inspection, a review of resident #2's physical examination dated 9-26-19, the field labeled address and telephone was blank. 2. A review of resident #3's physical examination dated 11-27-19, the field labeled address and telephone was blank. 3. Staff #1 acknowledged the telephone and address field was blank for residents #2 and #3 during the exit interview on 7-16-20.
Plan of Correction:	22VAC40-73-(5)-320-A The physical examination for resident #2 and resident #3 were corrected with the address and telephone number. Audits will be conducted on all physical examinations to ensure the address and telephone number are completed. Re-education will be provided to staff responsible for reviewing physical examinations to assure all information is completed, including address and telephone number. The Director of Nursing/Designee will conduct additional audits commencing after the date of the correction for a duration of six weeks to assure that all physical examinations are complete. Audit results will be reviewed for patterns and trends and findings reported to the Quality Assurance Committee.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for three of three residents. Evidence: 1. During the remote renewal inspection, a review of resident #1's uniformed assessment instrument (uai) dated 2-5-20 noted eating/feeding assessed as human help/physical assistance (hh/pa), however, the individualized service plan (ISP) dated 2-19-20 noted resident is sometimes spoonfeed, There is no documentation of length of time required to assist resident with feeding. Toileting and transferring assessed as not performed (TD/total dependent); however, the need is not included on the ISP. Dressing assessed as performed by others, however, the ISIP do not document who will perform task. Bowel assessed, incontinent greater than weekly, however, the need is not included on the ISP. Walking, wheeling and stairclimbing assessed on uai as not performed, however, the need is not included on the ISP. Mobility assessed human help/physical assistance (hh/pa), however, the ISP noted physical assistance by staff in turning and repositioning resident in bed/ turn every 2 hours.....repositioning in bed. UAI noted disoriented some spheres all time, however, ISP does not include orientation information. 2. A review of resident #2's uai dated 9-17-19 noted mobility as mechanical help (mh), however, the ISP dated 10-27-19 resident use feet/arms to propel self......outside of facility resident may require physical assistance to push and guide his wheelchair for direction and safety. UAI noted wanderguard, however, this need not on ISP. According to staff #1, the resident did use wanderguard at one time, but ISP did not indicate discontinued use. Resident #2's June 2020 physician's order noted occupational therapy (OT) evaluate and treat- strengthening and tranfers dated 9-30-19. A review of the record and ISP did not include services. A request for additional information on 7-14-20 provided documentation of services start of care 10-1-19 thru 11-29-19. Further review of the ISP did not include OT services beginning nor outcome achieve dated. 3. A review of resident #3's uai dated 12-26-19, mobility need assesse as mechanical help only (mh), however, the ISP dated 1-9-20 noted use of rolling walker....require supervision assistance during outings, to provide additional safety cueing in areas unfamiliar.... 4. Staff #1 acknowledged resident #1, #2, and #3's ISP did not include all assessed needs.
Plan of Correction:	This plan of correction is respectfully submitted as evidence of alleged compliance. The submission is not an admission that the deficiencies existed or that we are in agreement with them. It is an affirmation that corrections to the areas cited have been made and that the facility is in compliance with participation requirements. 22VAC40-73-(6)-450-C The ISPs for resident #1, resident #2, and resident #3 were corrected to appropriately identify the needs of the resident. Audits will be conducted of all UAI and ISPs to assure all assessed needs of each resident are appropriately addressed on the ISP. ISP re-education will be provided to staff responsible for ISPs to assure needs of the resident are appropriately documented. The Director of Nursing/Designee will conduct additional audits commencing after the date of correction for a duration of six weeks to assure that all ISPs completed reflect the assessed needs of the resident. Audit results will be reviewed for patterns and trends and findings reported to the Quality Assurance Committee.