VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Chambrel Williamsburg
3800 TREYBURN DRIVE
Williamsburg, VA 23185
(757) 220-1839

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Nov. 2, 2020 , Nov. 9, 2020 , Nov. 13, 2020 and Dec. 22, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 (2)- ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 (4)- STAFFING AND SUPERVISION 22VAC40-73 (5)- ADMISSION RETENTION AND DISCHARGE 22VAC40-73 (6)- RESIDENT CARE AND RELATED SERVICES 22VAC40-73 (10) Additional requirements for serious cognitive impairments

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 11-2-20 and concluded on 12-22-20. A complaint was received by the department regarding allegations in the areas of resident care and related services, administration and administrative services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the assistant executive director 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 #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure it complied with the facility?s own policies and procedures related to its resident agreement for a resident. Evidence: 1.During the complaint inspection regarding notification of resident?s rate increase for services, the facility was not able to provide documentation of the aforementioned increase for resident #1. 2.A review of resident #1?s residency agreement dated 1-15-20, noted, on page 2, Section I- Services and Accommodations; section B- Personal Service Plan, noted, ??.periodically throughout your residency, we will use a personal service assessment to determine the personal services you require. The personal assessment will be used to develop your Personal Service Plan. The results of the assessment and the cost or providing the additional personal services (the Personal Service Rate) will be shared with you?..? 3.Further review of the resident agreement, on page 6, Part III- Rates, section F- Rate Changes, noted??We will provide thirty (30) written notice of any change in rates or pricing for Basic Services, Personal Services, Select Services and Therapeutic Services. We may offer or require a change in Personal Service Plan when we determine additional services are requested or required. The new Personal Service Plan Rate resulting from a change in your Personal Service Plan is effective immediately after written notice is given.? 4.Interview with staff #3 and #4, neither individuals could provide documentation of notification of rate increase for services to the resident/or legal representative
Plan of Correction:	The following is the Plan of Correction for Brookdale Chambrel Williamsburg regarding the Statement of Deficiencies dated December 23, 2020. This Plan of Correction is not to be construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies, or any related sanction or fine. Rather, it is submitted as confirmation of our ongoing efforts to comply with statutory and regulatory requirements. In this document, we have outlined specific actions in response to identified issues. We have not provided a detailed response to each allegation or finding, nor have we identified mitigating factors. We remain committed to the delivery of quality health care services and will continue to make changes and improvement to satisfy that objective. 22VAC40-73-(2)-40A Resident #1 is has been discharged. The AL Director will audit resident personal service rate agreements for appropriate signatures acknowledging receipt of rate change. Personal service rate agreements needing signatures acknowledging notice of rate changes will result in arranging a family meeting to discuss care with the Health and Wellness Director and rate increase with the AL director. The AL Directors will be re-educated on obtaining acknowledging signatures on the personal service rate changes documentation per state regulation and Brookdale policy. Responsible party: AL Director AL Director or designee will audit 20% of resident personal service rate agreements monthly to verify written notice has been provided to the resident or his legal representative of any change in personal service plan rates per state regulations and Brookdale policy. This will be brought to the Quality Assurance meeting. Completion date: February 1, 2021 and on-going
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included all assessed needs. Evidence: 1. During the complaint inspection, a review of resident #1?s individualized service plan (ISP) updated 6-18-20 by the developer, did not include all assessed needs for resident #1. The resident?s initial assessment for placement in the facility?s safe, secure unit (scu) dated 1-14-20 noted resident to have ?poor judgement, difficulty concentrating, poor memory, very little if any abstract reasoning, limited thought process, and occasional agitation. However, the ISP did not address resident?s assessment. 2.A review of page #7 of resident #1?s ISP noted ?8-18-20- resident agitated with redirection, take for walks outside, call daughter to speak with him, and PL associates to take on daily walks?. Notation dated 9-11-20, ?resident found with another resident in his own room, PL in place? one-on-one ?24/7?. Another notation dated 10-1-20, resident has one-on-one, sitters with a local agency. Staff #3 and #4 acknowledged notations on ISP were concerns that were noted on the ISP but were not documented with all required components per regulations for an ISP.
Plan of Correction:	Resident #1 has been discharged. The Health and Wellness Director will audit resident Individualized Service Plans to verify assessed needs are included. The Health and Wellness will update individualized service plans as necessary per state regulations and Brookdale policy. The clinical staff will be re-educated on creating and updating the Individualized Service Plan per state regulation and Brookdale policy. Responsible party: Health and Wellness Director The Health and Wellness Director or designee will audit 10% of resident Individualized Service Plans monthly to verify assessed needs are included and discussed with the legal representative per state regulations and Brookdale policy. This will be brought to the Quality Assurance meeting. Completion date: February 1, 2021 and on-going
Standard #:	22VAC40-73-450-E
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the license, administrator, or his designee, the person who developed the plan, and by the resident or his legal representative. Evidence: 1.During the complaint inspection, a review of resident #1?s individualized service plan (ISP) dated 1-23-20 and signed by the developer did not include the signature of the resident or the legal representative.
Plan of Correction:	Resident #1 is has been discharged. The Health and Wellness Director will audit resident individualized service plans for appropriate signatures and dates by the licensed administrator or his designee, by the developer, and the legal representative acknowledging a review of the individualized service plan has been reviewed. Individualized Service Plans needing signatures will result in arranging a family meeting to discuss care with the Health and Wellness Director. The AL Directors and Health and Wellness Directors will be re-educated on obtaining signatures on the Individualized Service Plan per state regulation and Brookdale policy. Responsible party: Health and Wellness Director Health and Wellness Director or designee will audit 20% of resident Individualized Service Plans monthly to verify it has been reviewed with the resident or his legal representative and signed by the developer, the licensed administrator or designee, and the legal representative state regulations and Brookdale policy. This will be brought to the Quality Assurance meeting. Completion date: February 1, 2021 and on-going