VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harbor's Edge
One Colley Avenue
Norfolk, VA 23510
(757) 233-0475

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: July 23, 2020 and July 24, 2020

Complaint Related: No

Areas Reviewed:

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 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 07-23-2020 and concluded on 07-24-2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 40. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, and healthcare oversight. 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 #:	22VAC40-73-450-C
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) included a description of identified needs and date identified based on the Uniform Assessment Instrument (UAI) and physician?s orders, and the expected outcome and timeframe for expected outcomes. Evidence: 1. The following ISP?s did not include a description of the residents? identified needs and date identified, or the expected outcome and timeframe for expected outcomes: A. Resident #1?s current UAI dated 11-01-2019 documented the need for mechanical and physical assistance with dressing and mobility; however, the current ISP dated 11-01-2019 did not include documentation of the type of mechanical device that is needed for dressing or mobility. The ISP also did not include the dates identified or expected outcome and timeframe for expected outcomes for all of the resident?s identified needs documented on the ISP. B. Resident #2?s current ISP dated 10-01-2019 did not include the dates identified or expected outcome and timeframe for expected outcomes for all of the resident?s identified needs documented on the ISP. C. Resident #3?s physician?s order dated 11-01-2019 documented ?O2- 2L Nares Every shift as Needed for dyspnea, SOB 02 sats less than 90%.? The resident?s current ISP dated 11-01-2019 did not include the need for PRN oxygen, or the dates identified or expected outcome and timeframe for expected outcomes for all of the resident?s identified needs. 2. Staff #1 acknowledged resident #1, resident #2, resident #3 aforementioned ISP?s did not include a description of the residents? aforementioned needs, date the need was identified, or the expected outcome and timeframe for expected outcomes.
Plan of Correction:	1. No resident has been adversely affected from this deficient practice. 2. The Individualized Service Plans for Residents 1, 2, and 3 have been corrected. 3. Unit Manager or designee will ensure that all residents? needs are dated and described properly including time frame and outcome. 4. An audit of all Individual Services Plans will be performed by the Administrator to ensure the Individual Service Plans match all Physician orders as well as the UAI. 5. Unit Manager or designee will conduct a monthly audit for 3 months to ensure the Individual Service Plans are in uniform with the UAI and the expected outcomes.