VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Havenwood
50 Havenwood Drive
Lexington, VA 24450
(540) 463-2205

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Sept. 16, 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 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 standards 120 A, 270, 490 A and 680 I.

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 09/14/2020 and concluded on 09/16/2020. 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, staff schedules, dietary review, fire inspection report, health care oversight, health department inspection report, fire and emergency drills and sworn disclosures and criminal record checks for all staff hired since the last mandated inspection submitted by the facility to ensure documentation was complete. The LI and the Administrator had a discussion regarding standards 210 F and 680 E. 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 #:	22VAC40-73-210-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that direct care staff received 18 hours of training annually. EVIDENCE: 1. The record for staff 3, date of hire 12/16/2017, contained documentation that staff 3 had only received 17 hours of annual training for the annual period of 12/16/2018 through 12/15/2019. Interview with staff 1 confirmed that staff 3 had only completed 17 hours of annual training.
Plan of Correction:	The administrator will complete the (1) hour of training and have the nurse admin provide oversight quarterly to ensure all hours are obtained.
Standard #:	22VAC40-73-210-F
Description:	Based on staff record review and staff interview, 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 2, date of hire 02/18/2019, did not contain documentation that staff 2 had received 2 hours of infection control and prevention training for the annual period of 02/18/2019 through 02/17/2020. Interview with staff 1 confirmed staff 2 had not received 2 hours of infection control and prevention training. 2. The record for staff 3, date of hire 12/16/2017, contained documentation that staff 3 had only received 1 hour of infection control and prevention training for the annual period of 12/16/2018 through 12/15/2019. Interview with staff 1 confirmed staff 3 had only received 1 hour of infection control and prevention training.
Plan of Correction:	Administrator will complete 2 hrs infection control training for Staff 2 and (1) hour for Staff 3. Administrator will have nursing supervisor provide oversight quarterly to ensure all hours are obtained.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure residents? individualized service plan (ISP) included all required components. EVIDENCE: 1. The ISP for resident 1, dated 03/16/2020, showed the resident receives ?Home Health Services? and ?(Resident) will have Home Health Services provided to assist in his Catheter Care?; however, the ISP does not include a written description of the services the home health agency is providing. 2. The record for resident 1 contained a physician?s order, dated 06/02/2020, that stated ?*****TREATMENT***** O2: O2 @ 2 LITERS PER MINUTE AS NEEDED FOR DYSPNEA?. The ISP for resident 1 does not address oxygen therapy. 3. The Uniform Assessment Instrument (UAI) for resident 1, dated 03/16/2020, showed that the resident is ?Disoriented ? All spheres, some of the time? and ?Spheres affected: person, place and time?. The ISP, dated 03/16/2020, showed ?(Resident) will be oriented to time and place as needed. We have a large clock in the front room area to help along with assistance from Staff.?. Interview with staff 1 confirmed that the UAI is correct and the ISP is wrong. 4. The current ISP for resident 2 shows the resident started receiving hospice services on 09/08/2020; however, the ISP does not indicate what services the hospice agency is providing to resident 2.
Plan of Correction:	1. Resident ISP has been updated to include frequency of services and that the Home Health nurse will change catheter. 2. Oxygen Therapy was added to Resident ISP. 3. Orientation for place was added to resident ISP. 4. All Hospice services were added to Resident ISP to include Nursing, Aide, Chaplin and Social Worker. Plan of Correction: Administrator will provide more oversight review to ISPs to be sure they are updated properly.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, 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 diagnosis, condition or specific indications for administering each drug. EVIDENCE: 1. The most recent physician?s order for resident 1, dated 06/02/2020, does not include the diagnosis, condition or specific indications for administering the following medications: Trazodone 50 MG, Vitamin C 250 MG, Metformin 500 MG and Metformin 1,000 MG. 2. Physician?s order, dated 09/08/2020, does not include the diagnosis, condition or specific indications for administering the following medications: Pantoprzaole 40 MG, Bisoprolol-HCTZ 5-6.25 MG, Furosemide 20 MG, and Neurontin 300 MG.
Plan of Correction:	1. All diagnosis, condition or specific indications have been added to the resident's MAR (for administering) each day. Plan of Correction: The pharmacy was contacted and all resident MAR's have been reviewed and updated to include diagnosis and specific indications for administering each drug. The pharmacy has implemented a daily report to identify any drug entered without a diagnosis code - Admin also gave TA to Med Aides To review orders to be sure they include the proper documentation when order arrives and notify pharmacy if inaccurate.
Standard #:	22VAC40-73-680-E
Description:	Based on resident record review and staff interview, the facility failed to ensure treatments ordered by a physician or other prescriber were provided according to his instructions, documented and maintained in the residents' record. EVIDENCE: 1. The record for resident 1 contained a signed physician?s order, dated 06/02/2020, that stated ?*****TREATMENT***** O2: O2 @ 2 LITERS PER MINUTE AS NEEDED FOR DYSPNEA?. The record for resident 1 did not include documentation that treatment is being provided according to the physician?s instructions. 2. The record for resident 2 contained a signed physician?s order, dated 09/10/2020, that stated ?2. O2 @ 2.5 L NC Continuous?. The record for resident 2 did not contain documentation that treatment is being provided according to the physician?s instructions. 3. Interview with staff 1 verified that there is no documentation to show that oxygen therapy is being provided for residents 1 and 2 according to the physician?s instructions.
Plan of Correction:	All O2 orders were added to the MAR for each resident w/ O2 orders to ensure proper documentation. Please note: All orders were being followed per the dr orders per administrator.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure a valid physician?s order for oxygen contained all the required components. EVIDENCE: 1. The record for resident 2 contains a physician?s order, dated 09/10/2020, that showed ?2. O2 @ 2.5L NC Continuous?. The order does not contain the oxygen source. 2. The most recent physician?s order for resident 1, dated 06/02/2020, showed ?*****TREATMENT***** O2: O2 @ 2 LITERS PER MINUTE AS NEEDED FOR DYSPNEA?. The order does not contain the oxygen source.
Plan of Correction:	Both resident orders have been updated to include source as concentrator. Administrator spoke to Hospice to ensure they include source in all resident hospice order and nursing administrator will review for accuracy.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review and staff interview, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff 4, date of hire 06/25/2020, did not contain documentation that a criminal history record report was obtained within the first 30 days of employment. 2. Interview with staff 1 confirmed that there had not been a criminal history record report obtained for staff 4.
Plan of Correction:	The administrator did obtain a background check on 6/24/20 but did not receive it back from the State Police. (I had a copy that was sent) The state said they could not find it and another one was sent. Administrator will follow up with all background checks to be sure they are returned within the 30 day requirement.