VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Stratford House
1111 Main Street
Danville, VA 24541
(434) 799-2266

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: April 2, 2021 , April 6, 2021 , April 14, 2021 and April 19, 2021

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 32.1 Reported by persons other than physicians 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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 4/2/2021 and concluded on 4/19/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 46. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, one sitter record, staff schedules, fire/health inspections, medication management plan, infection control plan, and other documents submitted by the facility to ensure documentation was complete. 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 #:	22VAC40-73-1110-A
Description:	Based on resident record review, the facility failed to have a written determination and justification by the administrator to place a resident in the special care unit. EVIDENCE: 1. The record for resident 1 lacks the determination and justification from the licensee, administrator, or designee for the decision to place the resident in the special care unit.
Plan of Correction:	What has been done to correct? A form has been created to meet the licensing requirements. Resident #1 file has been updated with the appropriate documentation for justification in the Memory Unit. How will recurrence be prevented? The files for all other residents will be checked to ensure compliance. Person Responsible: ED, RCD and Designee will check residents file at admission or upon entry into special care unit to ensure compliance.
Standard #:	22VAC40-73-100-C-2
Description:	Based on document review, the facility failed to have a complete infection control plan. EVIDENCE: 1. The facility's infection control plan is missing requirements specified in 22VAC 40-73-100-C-2-a, d, f, and g.
Plan of Correction:	What has been done to correct? Actively working on updating. Once complete, it will be sent to LI for review. Person Responsible: ED
Standard #:	22VAC40-73-100-C-4
Description:	Based on document review, the facility failed to have a complete infection control plan. EVIDENCE: 1. The facility's infection control plan is missing requirements specified in 22VAC 40-73-100-C-4: Product specific instructions for use of cleaning and disinfecting agents (e.g., dilution, contact time, and management of accidental exposures).
Plan of Correction:	What has been done to correct? Actively working on updating. Once complete, it will be sent to LI for review. Person Responsible: ED
Standard #:	22VAC40-73-220-A
Description:	Based on private duty personnel (PDP) file review, the facility failed to obtain some required information. EVIDENCE: 1. The file for PDP 1 does not identify specific duties and the only resident named is identified as a prospective resident. There is no documentation to support that orientation and training regarding the facility's policies and procedures related to the duties of private duty personnel had been provided.
Plan of Correction:	What has been done to correct? Required documentation was obtained to be kept on file in the community. How will recurrence be prevented? Business Office Manager or designee will ensure that all required information is on file for any Private duty aide. Person Responsible: ED or designee will review to ensure that all required information is up to date.
Standard #:	22VAC40-73-250-C
Description:	Based on staff file review, the facility failed to obtain a completed sworn statement or affirmation for an employee prior to their employment date. EVIDENCE: 1. Staff 4 started work on 5/19/2020 and the sworn statement was dated 2/11/2021.
Plan of Correction:	What has been done to correct? Unable to correct because sworn statement was signed late. How will recurrence be prevented? Business Office Manager or Designee will ensure that all required information is in the associates file in compliance with Licensing Standards. Person Responsible: ED to review every new hire.
Standard #:	22VAC40-73-260-A
Description:	Based on documentation and interview, the facility failed to ensure a new staff person received first aid training within 60 days of hire. EVIDENCE: 1. Staff 2 began employment on 12/15/2020 and the staff record has not documentation to support that first aid training has been obtained. In a phone interview, staff 1 confirmed that the training has not been done.
Plan of Correction:	What has been done to correct? Unable to correct time period for First Aid training has expired. How will recurrence be prevented? Business Office Manager or Designee will ensure that all required training will be completed and documented in the associates file to be in compliance with Licensing Standards. Person Responsible: ED or designee will randomly review charts for compliance.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and interview, the facility failed to complete a uniform assessment (UAI) in accordance with Assessment in Assisted Living Facilities (22VAC30-110). EVIDENCE: 1. The UAI dated 4/16/2020 for resident 2 shows this resident needs no help with bladder and bowel incontinence. A review of the individualized service plan and interview with staff 1 reveal that the correct assessment is actually External Device - Self Care. The same UAI shows that resident 2 needs mechanical assistance with using a wheelchair, and interview with staff 1 revealed that the wheelchair has no mechanical modifications and the actual assessment should have been no assistance needed. 2. The UAI dated 2/17/2021 for resident 3 shows this resident needs mechanical and human help with physical assistance when using a wheelchair, and interview with staff 1 reveals that the wheelchair has no mechanical modifications and the actual assessment should have been human help with physical assistance.
Plan of Correction:	What has been done to correct? UAI's for residents #2 and #3 were corrected during the remote visit. How will recurrence be prevented? UAI's will be reflective of all identified needs of the resident to ensure that the basic needs of the residents are met. Person Responsible: ED will complete random audits to ensure ongoing compliance
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to obtain required signatures on an individualized service plan (ISP). EVIDENCE: 1. The ISP dated 4/16/2020 for resident 2 shows it was reviewed/modified on 11/6/2020 and 1/8/2021. On both of those dates, there are no signatures.
Plan of Correction:	What has been done to correct? Signature obtained for resident #2. How will recurrence be prevented? All ISP's will be reviewed to ensure that signatures are present for compliance. Person Responsible: ED, RCD and or ARCD will audit all ISP's at the time of admission and those completed in each month to ensure compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to have a complete medication management policy. EVIDENCE: 1. The facility's medication management policy, sections Med01 through Med49 in the CLINICAL POLICY & PROCEDURE MANUAL - VIRGINIA lacks sections 22 VAC 40-73-640-A-6 and 9.
Plan of Correction:	What has been done to correct? Actively working on updating. Once complete, it will be sent to LI for review. Person Responsible: ED Due Date: 5/13/2021