VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Inspirit Hilltop Operator LLC
111 Denny Lane
Winchester, VA 22603
(540) 667-5323

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: July 20, 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 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 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 07/20/20 and concluded on 08/13/20. The interim Executive Director was contacted by to initiate the inspection. The interim ED reported that the current census was 56. The inspector emailed the interim ED a list of items required to complete the inspection. The inspector reviewed five resident records, four staff records, medication administration records for a selected number of residents and the facility medication management plan 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.

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based upon review of staff records, the facility failed to maintain all required documents in staff records. EVIDENCE: 1) The record for staff A did not contain documentation of the required 4 hour annual refresher training for registered medication aides. a. Staff A has been a registered medication aide since 05/30/12. 2) The record for staff A did not contain documentation of the required 4 hour annual refresher training for registered medication aides. a. Staff B has been a registered medication aide since 01/09/09. 3) The record for staff C hired 06/25/19 does not include a certificate of completion for the DSS approved 40 hour direct care training.
Plan of Correction:	Resident Wellness Director, Resident Care Coordinator, Executive Director or designee will ensure required documents are in staff records. Executive Director, Business Office Manager or designee will complete an audit of all staff records to ensure compliance. Resident Wellness Director, Resident Care Coordinator, Executive Director or designee will ensure that registered medication aide training documents will be completed and/or filed in staff records.
Standard #:	22VAC40-73-325-A
Description:	Based upon review of residents' records, the facility failed to ensure a fall risk rating is on file as required. 1) There is no annual fall risk rating on file for resident A (admitted 02/23/17) 2) There is no annual fall risk rating on file for resident B (admitted 05/04/18). 3) The is no initial fall risk rating on file for resident D (admitted 06/27/20).
Plan of Correction:	Resident A Fall Risk Rating was completed on 10/22/19. Resident B Fall Risk Rating was completed on10/22/19. Resident C Fall Risk Rating was completed on 08/04/20
Standard #:	22VAC40-73-440-D
Description:	Based upon review of residents' records, the facility failed to ensure the Uniform Assessment Instrument (UAI) is completed as required. 1) The second page of the UAI is missing for resident A. 2) The UAIs for residents B, C, D and E are not signed by the administrator.
Plan of Correction:	Resident A UAI was completed on 11/26/19. Resident Wellness Director or designee will ensure that UAI?s are signed by the administrator. Resident Wellness Director or designee will complete an audit to ensure compliance.
Standard #:	22VAC40-73-450-C
Description:	Based upon review of resident's records, the facility failed to ensure all assessed needs are identified on the Individualized Service Plan (ISP). EVIDENCE: 1) The ISP for resident A indicates status of DNR effective 11/26/19. The DNR on record for resident A is dated 05/30/18. a. The UAI indicates physical and mechanical assistance is needed with transferring and bathing. Mechanical supports are not identified on the ISP. b. The UAI indicates physical and mechanical assistance is needed with mobility. The ISP indicates on mechanical assistance. c.The UAI indicates physical and mechanical assistance needed with ambulation. Only mechanical assistance is indicated on the ISP. d. Lap belt, PRN oxygen and use of bed rails are not indicated on the ISP. 2) The UAI for resident B indicates mechanical and physical assistance is needed with bathing. Type of mechanical supports are not identified on the ISP. a. The UAI indicates mechanical and physical assistance needed with toileting and transferring. Mechanical supports are not indicated on the ISP. b.The UAI indicates no assistance is needed with walking. The ISP indicates walking is not performed. c. The UAI indicates physical assistance is needed with wheeling. This is not indicated on the ISP. d. The UAI indicates physical and mechanical assistance is needed with mobility. This is not identified on the ISP. e. Bed rails and PRN oxygen are not indicated on the ISP. 3) The UAI for resident C indicates no assistance is needed with transferring. The ISP indicates use of walker, chair arm and rails. a. The UAI indicates bowel incontinence. The ISP indicates resident is continent of bowel and bladder. b. Resident C has a catheter. This is not indicated on the ISP. c. The UAI indicates walking is not performed. The ISP indicates use of walker for transferring. d. UAI indicates no assistance is needed with mobility. ISP indicates use of wheelchair. 4) The UAI for resident D indicates supervision is needed with dressing and transferring. ISP indicates physical assistance is needed. a. UAI indicates psychological evaluation needed. Mental health is not indicated on the ISP. 5) The UAI for resident E indicates no assistance is needed with bathing. The ISP indicates standby assistance and use of hand rails.
Plan of Correction:	An audit of all ISP?s will be completed to ensure compliance. ISP?s will be update accordingly to ensure compliance.Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-450-E
Description:	Based upon review of residents records, the facility failed to ensure the ISP contained required signatures. EVIDENCE: 1) The ISPs for residents A, B, C, D and E do not contain a signature of the resident or the resident's legal representative. 2) The ISPs for residents B, D, and E do not contain signature of person completing the plan.
Plan of Correction:	Resident Wellness Director or designee will ensure that ISP?s contain required signatures. An audit of all ISP?s will be completed to ensure compliance. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-550-G
Description:	Based upon review of residents' records, the facility failed to ensure an acknowledgment indicating the review of resident's rights is on file. a. There is no acknowledgment of an annual review resident rights on record for resident B (admitted 05/04/18). b. There is no acknowledgment of a review of resident rights on record for resident D (admitted 06/27/20).
Plan of Correction:	All residents will have their resident rights reviewed annually. Documentation will be kept on file. The Activity Director will ensure this is completed.The Administrator will be responsible for compliance.
Standard #:	22VAC40-73-640-A
Description:	Based upon review of the facility's medication management plan and a review of resident and staff records, the facility failed to implement procedures as outlined in the plan. EVIDENCE: 1) The medication management plan indicates the contracted pharmacy and/or a pharmacy of the residents? choice can provide medications. New medication orders and/or refills will be provided within 24 hours. STAT orders (4 hours or less) will be provided by contracted pharmacy unless family member assures nursing staff that medication will be received within 4 hours or less. After hour?s orders (orders received after 5 pm and/or weekends) will be provided within 24 hours. 2) The plan indicates if a medication is not available at the scheduled time of administration, the pharmacy and the supervisor will be notified. Charting ?med not available? on the EMAR alone, does not fulfill this requirement. 3) The plan indicates licensed nursing staff will review EMAR?s on a monthly basis for accuracy, correctness and proper documentation ? there shall be no omission/holes left on the EMARs. 4) The plan indicates medication aides will successfully complete the Department of Social Services approved 4 Hour medication aide refresher annually and when deemed appropriate by the Resident Wellness Director or designee to maintain competency. 5) The plan indicates supervisory staff evaluates the training needs of their employees and supervisors provide or arrange for ongoing training to meet the developmental needs of their employees.The Resident Wellness Director or designee will be responsible for orientation and determining/maintaining competency of the community staff authorized to administer medications.
Plan of Correction:	Resident Wellness Director with the support of Resident Care Coordinator or designee will implement the medication management plan methods to ensure compliance. Medications will be administered in accordance with physicians? instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the VA BON. Resident Wellness Directors with the support of Resident Care Coordinator or designee will complete weekly medication audits to ensure compliance.
Standard #:	22VAC40-73-680-D
Description:	Based upon review of residents' records, the facility failed to ensure medications are administered in accordance with physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: Documentation in the Medication Administration Record (MAR) indicates the following medications were not available for administration: 1) Cultrurelle was not available for resident A on 07/01/20 at 8:00pm and 07/02/20 at 8:00am; "waiting on delivery." ; 07/15/20 at 8:00am "order review."; 07/20/20, 07/22/20, 07/25/20 at 8:00pm; 07/26/20 at 8:00am, 07/26/20, 07/29/20 and 07/31/20 at 8:00pm "not available." 2) Potassium Chloride was not available for resident A on 07/02/20 at 8:00am "waiting on delivery"; 07/06/20 at 8:00am "order review"; 07/08/20 and 07/09/20 and 07/10/20 at 8:00am "outside of parameters"; 07/11/20 and 07/12/20 at 8:00am "order review"; 07/14/20 at 8:00am "not available"; 07/15/20 at 8:00am "order review" ; 07/20/20, 07/21/20, 07/26/20 at 8:00am "not available"; 07/29/20 at 8:00am "waiting on delivery." 3) Resident E has the following order: Humalog KwikPen 100unit-Administer three times daily before meals per sliding scale: 150-199=1 Unit; 200-249=3 Units; 250-299=5 Units; 300-349=7 Units; 350-400=8 units a. The order does not include subcutaneous route or parameters when to notify the physician. b. There is no documentation of resident's blood glucose on 07/01/20 and 07/02/20 at 7:30am, 11:30am and 4:30pm or administration of Humalog due to being "outside parameters. c. There is no documentation of resident's blood glucose on 07/03/20 at 11:30am or administration of Humalog due to being "outside parameters. d. Documentation indicates Humalog was not administered on 07/03/20 at 4:30pm due to "outside of parameters" There is no documentation of resident's blood glucose. e. Documentation in the MAR indicates resident's blood glucose was 168 on 07/04/20 at 7:30am and Humalog was not administered due to being "outside parameters." f. Documentation in the MAR indicates resident's blood glucose was 168 on 07/04/20 at 11:30am and Humalog was not administered due to being "outside parameters." g. Documentation in the MAR indicates resident's blood glucose was 150 on 07/05/20 at 11:30am and was not administered due to being "outside parameters." h. Documentation in the MAR indicates resident's blood glucose was 167 on 07/05/20 at 4:30pm and Humalog was not administered due to being "outside parameters." i. Documentation in the MAR indicates resident's blood glucose was 172 on 07/07/20 at 11:30am and Humalog was not administered due to being "outside parameters." j. Documentation in the MAR indicates resident's blood glucose was 182 on 07/08/20 at 11:30am and Humalog was not administered due to being "outside parameters." k. Documentation in the MAR indicates resident's blood glucose was 150 on 07/08/20 at 4:30pm and Humalog was not administered due to being "outside parameters." l. Documentation in the MAR indicates resident's blood glucose was 253 on 07/09/20 at 11:30am and only 3 Units of Humalog were administered. m. Documentation in the MAR indicates resident's blood glucose was 153 on 07/10/20 at 11:30am and 3 Units of Humalog were administered. n. Documentation in the MAR indicates resident's blood glucose was 171 on 07/30/20 at 11:30am and Humalog was not administered due to being "outside parameters." o. There is no documentation of physician notifications for refusals on 07/11/20, 07/14/20 07/16/20 07/18/20, 07/19/20, 07/25/20, 07/27/20 and 07/29/20. . p. The MAR indicates resident's blood glucose was 118 on 07/28/20 at 7:30am. Documentation indicates "given." 4)The MAR for resident F indicates Tylenol was not available on 07/01/20-07/02/20; Basaglar was available on 07/15/20-07/17/20; 07/26/20-07/27/20.
Plan of Correction:	Resident Wellness Director with the support of Resident Care Coordinator or designee will implement the medication management plan methods to ensure compliance. Medications will be administered in accordance with physicians? instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the VA BON. Resident Wellness Directors with the support of Resident Care Coordinator or designee will complete weekly medication audits to ensure compliance.
Standard #:	22VAC40-73-690-B
Description:	Based upon review of documentation, the facility failed to ensure an annual medication review was completed for each resident. EVIDENCE: 1) There is no documentation on file indicating a medication review has been completed for each resident except for those residents who self-administer all medications.
Plan of Correction:	Resident Wellness Director or designee will ensure annual medication review is completed for each resident who does not self-administer medications by the facilities contracted pharmacy. The facilities newly contracted pharmacy did complete a medication cart review in February 2020 however, this did not fully meet the state requirements.
Standard #:	22VAC40-73-930-D
Description:	Based upon review of residents' records, the facility failed to ensure the specific minimal frequency of daily rounds is included on the Individualized Service Plan (ISP). EVIDENCE: The ISP for residents A and B do not specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies of other anticipated resident needs.
Plan of Correction:	Resident Wellness Directors, Resident Care Coordinator or designee will ensure specific minimal frequency of daily rounds is included on the ISP for residents with an inability to use the signaling device. An audit of all ISP?s will be completed to ensure compliance. ISP?s will be update accordingly to ensure compliance.Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-950-E
Description:	Based upon review of documentation, the facility failed to ensure a semi-annual review of the emergency preparedness and response plan was completed with residents. EVIDENCE: There is no documentation on file that a review was completed with residents. Documentation indicates the last review was with staff members on 05/22/20 and 06/05/20.
Plan of Correction:	The emergency preparedness and response plan will be reviewed with all residents twice a year by the Administrator or designee.This review will be documented and kept on file. The Administrator will be responsible for compliance of this regulation.
Standard #:	22VAC40-73-970-E
Description:	Based upon review of documentation, the facility failed to ensure the record for fire and emergency evacuation drills included all required information. EVIDENCE: The form submitted for documenting fire drills does not indicate a specific time of the drill on 04/25/20 and on 05/27/20. a. On 04/25/20 time is indicated as 11:00pm to 7:30am. b. On 05/27/20 time is indicated as 7:00am to 3:30pm. c. The last section of the form indicates time as 3:00pm to 11:30pm; there is no notification of method used indicated. The sections for number of staff participating, any special conditions simulated, amount of time to complete the drill, weather conditions and problems encountered are all left blank.
Plan of Correction:	The Administrator or designee will ensure the fire drill log and emergency evacuation drill log will be filled out accurately with all required information.The Administrator will be responsiblefor compliance with this regulation.
Standard #:	22VAC40-73-990-C
Description:	Based upon review of documentation, the facility failed to ensure once every six months all staff currently on duty on each shift participated in an exercise in which procedures for resident emergencies are practiced. EVIDENCE: Documentation indicates the last practice was completed on 01/31/20 and did not include all staff for each shift.
Plan of Correction:	All staff will participate every 6 months in the required resident emergency exercises as noted in this regulation.Documentation will be completed and kept on file.The Administrator will be responsible for compliance of this regulation.
Standard #:	22VAC40-90-40-B
Description:	Based upon review of residents' records, the facility failed to ensure a criminal history report was obtained. EVIDENCE: A criminal history report for staff E hired 01/18/19 is not on file in the facility.
Plan of Correction:	All new employees will have a criminal history report prior to or within 30 days of the first day of work. Report will be filed in employee record.The Administrator or designee will obtain criminal history report. The Administrator will be responsible for compliance.