VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Highland House
3501 Longdale Furnace Road
Clifton forge, VA 24422
(540) 862-4271

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Sept. 2, 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 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 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Technical Assistance:

To ensure that the facility had a thorough understanding of standards, the LI and the Administrator had a discussion regarding standard 680I.

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 08/31/2020 and concluded on 09/03/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 16. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, current activities calendar, annual fire inspection, annual health inspection,staff schedule for past two weeks, and most recent dietary review submitted by the facility to ensure documentation was complete. The LI and the Administrator had a discussion regarding standards 210B, 260A and 620A. 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 #:	22VAC40-73-210-B
Description:	Based on staff record review, the facility failed to ensure that direct care staff received 18 hours of training annually. EVIDENCE: 1. The record for staff 1, date of hire 11/05/2014, contained documentation that staff 1 had only received 13 hours and 10 minutes of annual training for the annual period of 11/05/2018 through 11/04/2019. Interview with staff 2 confirmed that staff 1 had only completed 13 hours and 10 minutes of annual training.
Plan of Correction:	The Administrator will follow the in-service calendar to ensure that all staff is compliant with 18 hours of yearly in-service training.
Standard #:	22VAC40-73-210-F
Description:	Based on staff record review, the facility failed to ensure all staff had at least two hours of infection control and prevention training annually. EVIDENCE: 1. The record for staff 1, date of hire 11/05/2014, did not contain documentation that staff 1 had received 2 hours of infection control and prevention training for the annual period of 11/05/2018 through 11/04/2019. Interview with staff 2 confirmed staff 1 had not received 2 hours of infection control and prevention training.
Plan of Correction:	The Administrator will ensure that all staff will have 2 hours of Infection control within the training year. 1 hour of Infection control training will be scheduled at least 2x yearly.
Standard #:	22VAC40-73-320-A
Description:	Based on resident record review, the facility failed to ensure that physical examinations were completed as required prior to a resident?s admission. EVIDENCE: 1. The ?ADMISSSION/RETENTION REPORT OF PHYSICAL EXAMINATION? for resident 1, dated 03/03/2020, did not contain whether the resident is or is not capable of self-administering medication.
Plan of Correction:	The Administrator will review all history and physicals prior to admission for accuracy. H&P forms will be returned to the physician if not complete.
Standard #:	22VAC40-73-440-D
Description:	Based on resident record review and staff interview, the facility failed to complete the Uniform Assessment Instrument (UAI) as required. EVIDENCE: 1. The private pay UAI for resident 1, dated 03/05/2020, did not indicate whether the resident needs help with eating/feeding. Also, the UAI showed that the resident is ?disoriented ? some spheres, some of the time? but did not indicate what spheres are affected. Interview with staff 2 revealed resident 1 does not need assistance with eating/feeding and the spheres affected are time and place. 2. The private pay UAI for resident 2, dated 03/11/2020, showed that the resident is ?disoriented ? some spheres, all the time? but did not indicate what spheres are affected. Interview with staff 2 revealed that spheres affected are time, place and people. 3. The private pay UAI for resident 2 showed the resident needs physical assistance with dressing, toileting, and transferring. The individualized service plan (ISP), dated 03/12/2020, showed that resident 2 needs physical and mechanical assistance with dressing, toileting, and transferring. Interview with staff 2 revealed that the ISP is correct for all three, and the UAI assessment is incorrect for all three.
Plan of Correction:	The Administrator will review all UAI's upon completion to ensure all UAI's are complete and accurate. The UAI and ISP's for Residents 1 and 2 will be redone to appropriately reflect needs. The UAI and ISP will be compared to ensure the information matches.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review and staff interview, the facility failed to ensure that physician or other prescriber orders for administration of all prescription and over-the-counter medications and dietary supplements included the dosage and identified the diagnosis, condition or specific indications for administering each drug. EVIDENCE: 1. Resident 1 was admitted to the facility on 03/05/2020. The ?ADMISSION/RETENTION REPORT OF PHYSICAL EXAMINATION? for resident 1, dated 03/03/2020, included a ?Medication History? that interview with staff 2 indicated was the most recent physician?s orders for resident 1. 2. The ?Medication History? did not identify the diagnosis, condition or specific indications for administering each drug for the following medications: Lisinopril, Verapamil HCI ER, Tamsulosin HCI, CVS Allergy Relief, Omega 3, Allopurinol, and Rivastigmine Tartrate. The medication ?Omega 3? did not include the dosage of the medication.
Plan of Correction:	The Administrator will review all physician's orders. They will include the dosage and identify the diagnosis, condition or specific indications for administering each drug. The signed physician's order will be reviewed by the Administrator prior to admission to ensure the required information is included for all medications. If not correct, the physician will be notified for corrections.