VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living Communities
201 & 202 Lillian Lane
Lynchburg, VA 24502
(434) 385-5102

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Oct. 5, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 monitoring inspection was initiated on 10/05/2020 and concluded on 11/09/2020. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. 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 did not support the self-report of non-compliance with standards or law; however, any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on resident record review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that negatively affected or threatened the life, health, safety or welfare of residents. EVIDENCE: 1. The record for resident 1 contained a note by staff 1, dated 09/23/2020 at 4:34 PM, that stated ?E.D. called son, (resident?s son) and let him know his dad got out and was walking up Lillian Lane when a staff member saw him and redirected him back. E.D. told son that they need to have a companion with him at families? expense 24 / 7 to redirect him?. 2. Interview with staff 1 verified that the regional licensing office was not informed of this incident due to the facility not feeling as if it was a reportable incident. 3. The individualized service plan (ISP) for resident 1, with an identified need date of 09/25/2020, showed the following description of needs and services to be provided by all staff, : ?Special Care Unit or Secured Unit ? Needs secure unit due to not being able to recognize danger due to cognitive impairment?. 4. Interview with staff 1 revealed that resident 1 was placed in the special care unit on 09/25/2020.
Plan of Correction:	What: At the time of the event, the Executive Director did not consider the occurrence of Resident #1 walking outside a threat to the resident?s life or safety because a staff member was observing the resident and intervened when the resident breached the stopping point, therefore the incident was not reported to DSS. The Executive Director did not ensure that the details of the event were accurately described in the resident record so, as a result, while the event did not appear to be a reportable event it should, in fact, have been reported. How: The Executive Director or designee will review incidents daily, conduct investigations, verify account and documentation accuracy and submit to the regional licensing office within 24 hours any incidents or events that meet the reporting requirements. If the Executive Director has an incident and is unsure if it meets the requirements, DSS will be consulted. Ongoing: Executive Director or designee will conduct a monthly audit of internal incidents and reported incidents to verify reportable events have been reported in accordance with the regulation. Reports of incidents and reportable incidents will be submitted to the quality assurance committee quarterly.
Standard #:	22VAC40-73-460-D
Description:	Based on resident record review, the facility failed to provide supervision of resident schedules, care and activities, including attention to specialized needs, such as wandering from the premises. EVIDENCE: 1. The record for resident 1, admitted 08/27/2020, contained The REPORT OF RESIDENT PHYSICAL EXAMINATION, dated 08/22/2020, and showed that the resident does have a significant medical history of dementia. The REPORT OF RESIDENT PHYSICAL EXAMINATION also stated on page 2 that ?According to son, pt has dementia and hx of wandering off, police called?. 2. The record for resident 1 contained a note by Collateral 1, dated 08/28/2020, that showed ?H&P reviewed from previous PCP. It is noted patient has a history of wandering off?. 3. The uniform assessment instrument (UAI) for resident 1, dated 08/24/2020, showed ?Wandering/Passive ? weekly or more? and that resident is ?Disoriented ? some spheres, some of the time? and ?Spheres affected ? place, time, situation?. 4. The individualized service plan (ISP) for resident 1, with an identified need date of 08/24/2020 to be provided by all staff of the facility, showed the following description of needs and services to be provided by staff of the facility, : ?Wandering, Passive behaviors, weekly or more. Resident wanders and needs redirection back to his room ? involve into small group activities, redirection, coaxing into activity sessions? and ?Disorientation of place, time, situation, some spheres some of the time ? May orient upon discretion. Support resident during episodes of disorientation, reassure safety at the facility?. The ISP also showed the following description of needs and services to be provided by family and staff of the facility, showed the following description of needs and services to be provided by family and staff, : ?Mobility (supervision) ? Resident needs supervision when going outside facility?. 5. The record for resident 1 contained a note by staff 1, dated 09/23/2020 at 4:34 PM, that stated ?E.D. called son, (resident?s son) and let him know his dad got out and was walking up Lillian Lane when a staff member saw him and redirected him back. E.D. told son that they need to have a companion with him at families? expense 24 / 7 to redirect him?. From the facility, Lillian Lane is approximately 0.2 miles long and leads to Graves Mill Road which is a four lane highway. 6. The record for resident 1 contained a note by Collateral 2, dated 09/25/2020 at 1:45 PM, which stated ?Patient has been found wandering in the halls and actually exited the facility without supervision. Patient unable to recognize danger specifically in the evening and at night.? and ?Patient admits he continues to have hallucinations at night.?
Plan of Correction:	What: Based on resident #1's UAI, the resident required supervision while on the community outside grounds, and an ISP was developed for staff to monitor and redirect resident when wandering. On the day of the occurrence resident #1 was observed by a staff member who redirected the resident into the community after observing the resident breaching the agreed upon walking path stop point for residents. Documentation in the resident?s record does not accurately reflect the event. Resident #1 no longer residents in the community. How: Executive Director and Resident Care Director audited the records of assisted living residents to identify individuals with cognitive impairment, history of wandering, and requires supervision while outside. A list of these residents and their photos will be maintained in a binder at the front desk. This binder will not contain any protected health information. (Attachment A). The front desk staff will alert direct care staff if a resident who requires supervision is requesting to go outside. If a resident opens the door to exit the community the receptionist will follow and remain with the resident and radio for assistance. This binder will be completed immediately and all managers and front desk staff will be in-serviced on this process prior to working their next shift. The remaining staff are receiving in-service training from 11/9/2020 through 11/30/2020 regarding how to respond to any resident who requires supervision with mobility in Assisted Living. (Attachment B) Ongoing: Resident Care Director or designee will add residents to the binder if indicated after conducting resident assessments. The binder will be audited each month by the Resident Care Director or designee. Resident Care Director will monitor residents for any change in resident condition and determine if resident's needs can be met in assisted living. Monthly QA audits will be submitted by the Resident Care Director or designee and reviewed at the Quarterly QA meeting.