VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LlVING AT CHURCHLAND HOUSE
4916 West Norfolk Road
Portsmouth, VA 23703
(757) 483-1780

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: Sept. 29, 2020 , Sept. 30, 2020 and Oct. 1, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 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 complaint inspection was initiated on 9/24/2020 and concluded on 10/2/2020. A complaint was received by the department regarding allegations in the areas of Staffing and Supervision, Admission, Retention and Discharge of Residents, Resident Care and Related Services, and Additional Requirements for Facilities that care for Adults with Serious Cognitive Impairments. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-1090-A
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure that prior to admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: 1. Resident #2 was admitted to the safe, secure environment (SSE) on 4/14/2020. Resident #2?s record contained an ?Assessment of Serious Cognitive Impairment? form dated 9/25/2020, completed by a nurse practitioner. 2. Staff #1 acknowledged resident #2?s record did not contain an assessment by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare.
Plan of Correction:	All Serious Cognitive Impairments forms have been reviewed and reconciled to ensure they are signed by independent physician or clinical psychologist. ED and RCD will review all Serious Cognitive Impairments forms upon Admission to ensure that the form is signed by independent physician or clinical psychologist for regulatory compliance. Person Responsible: ED and RCD
Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure the physical examination report listed the description of the person?s reactions to known allergies. Evidence: 1. Resident #1?s physical examination report dated 10/10/2019 identified the resident is allergic to Gabapentin and Lyrica; however, the physical exam did not contain a description of the person?s reactions to the known allergies. 2. Staff #1 acknowledged Resident #1?s physical examination dated 10/10/2019 did not include the aforementioned information.
Plan of Correction:	RCD is auditing all H&Ps for reactions to identified allergies. ED and RCD will review all H&P?s upon Admission and Change of Condition to ensure that reactions are added to all allergies listed. Person Responsible: ED and RCD
Standard #:	22VAC40-73-325-B
Complaint related:	Yes
Description:	Based on record review and discussion, the facility failed to ensure the fall risk rating was reviewed and updated after a fall. Evidence: 1. The following incident reports were received documenting resident falls, with no fall risk ratings updated after each fall: 2. An incident report received 4/20/2020 documented Resident # 2 had a fall on 4/19/2020. 3. An incident report received 4/25/2020 documented Resident #4 had a fall on 4/24/2020 and 5/6/2020. 4. An incident report received 5/26/2020 documented Resident #1 had a witnessed fall on 5/19/2020. 5. Staff #1 acknowledged there were no fall risk ratings completed after Resident #2?s, Resident # 4?s, and Resident #1?s falls.
Plan of Correction:	All Incidents involving falls will be reviewed and Fall Risk Assessments conducted according to regulatory standards with interventions implemented as indicated. Fall Risks Assessments will be conducted per regulatory standards. Person Responsible: RCD, ARCD, and Supervisors
Standard #:	22VAC40-73-440-A
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to complete the Uniform Assessment Instrument (UAI) whenever there is a significant change in the resident?s condition. Evidence: 1. Resident #1?s UAI dated 10/18/2019 documented Resident #1 receives Human Help, physical assistance with dressing, Human Help supervision with toileting, Mechanical Help/Human Help supervision with transferring, and Mechanical Help/Human Help physical assistance with mobility. 2. Resident #1?s Individualized Service Plan dated 11/2/2019 documented Resident #1 receives supervision for dressing, stress incontinence for toileting, Mechanical Help for transferring, and Mechanical Help/Human Help for mobility, which Staff #1 acknowledged was correct. 3. Staff #1?s acknowledged Resident #1?s UAI dated 10/18/2019 was incorrect in the areas of dressing, toileting, transferring, and mobility and the ISP dated 11/2/2019 was correct in the areas of dressing, toileting, transferring, and mobility.
Plan of Correction:	All Resident UAIs will be reviewed and reconciled if indicated for Change of Condition. ED, ARCD and RCD will continue to review UAI and ISPs to ensure accuracy and information updated as Change of Condition occurs. Person Responsible: RCD & ARCD
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record review and discussion, the facility failed to ensure the comprehensive Individualized Service Plan (ISP) included the date of identified needs, the time frame for expected outcome, and date outcome achieved. Evidence: 1. Resident #4?s ISP dated 8/14/2020 documented identified needs; however, the ISP did not contain any dates to identify when the need was addressed, the time frame for expected outcome, or date outcome achieved for any of the services listed. 2. Staff #1 acknowledged there were no dates on Resident #4?s ISP.
Plan of Correction:	All Resident UAIs will be reviewed and reconciled if indicated for Change of Condition. ED, ARCD and RCD will continue to review UAI and ISPs to ensure accuracy and information updated as Change of Condition occurs. Person Responsible: RCD & ARCD