VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hope Haven
24532 Prince Edward Highway
Rice, VA 23966
(434) 392-9276

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 5, 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.

Technical Assistance:

To ensure that the facility had a thorough understanding of the standards, the LI and the Administrator had a discussion regarding standard 290 A.

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 05/05/2021 and concluded on 05/11/2021 by the licensing inspector assigned to the facility in conjunction with another licensing inspector. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 7. The inspector emailed the Administrator a list of items required to complete the inspection. The inspectors reviewed 2 resident records, 2 staff records, recent health care oversight, most recent health department and fire inspections, sworn disclosure and criminal record check for employees hired since the last mandated inspection, dates of the past 3 fire drills, recent six month practice of plan for resident emergencies, recent pharmacy review and recent dietitian review of special diets submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) included all required components. EVIDENCE: 1. The ISPs for resident 1 and 2, dated 01/21/2021, stated that medications are administered by direct care staff. An interview with staff 2 indicated that staff who are registered medication aides (RMAs) are responsible for administering medications to both residents 1 and 2. 2. The ISP for resident 1, dated 01/21/2021, stated that 24 hour supervision is needed due to the resident having aggressive behaviors. The ISP indicated that direct care staff will provide supervision as well as prevent behaviors as needed, administer proper medication, and provide transportation to the community services board (CSB) or for crisis services; however, the ISP did not elaborate on how staff will attempt to prevent aggressive behaviors or how staff will address behaviors when they occur. In addition, an interview with staff 2 indicated that staff members who are registered medication aides will administer proper medication, and facility administration or mental health caseworkers will transport the resident to the CSB or for crisis services as needed. 3. The ISP for resident 1, dated 01/21/2021, stated that the resident requires qualified mental health professional (QMHP) services due to a diagnosis of schizophrenia. The ISP for resident 2, dated 01/21/2021, stated that the resident requires mental health services from a QMHP due to his Diagnosis of Mood Disorder. The ISPs for both resident 1 and 2 also stated that mental health services would be provided by direct care staff. An interview with staff 2 indicated that the mental health services are provided by mental health caseworkers and not direct care staff for residents 1 and 2. 4. The ISP for resident 2, dated 01/21/2021, stated that the resident has been diagnosed with sleep apnea which requires him to use a CPAP machine and mask every night; however, the ISP does not include a description of services to be provided or who will provide these services. 5. The ISP for resident 2, dated 01/21/2021, stated that the resident is known to be allergic to and/or have allergic reactions to by and tetracycline; however physician?s order, dated 05/05/2021, indicated that resident 2 is allergic to Hydroxyzine-vistarill and Tetiacybines. Interview with staff 2 revealed that the ISP is incorrect.
Plan of Correction:	Part 1-The Administrator and ALF Coordinator reviewed 22VAC40-73-(6)-450-C, the noted ISPs, and all current ISPs for each resident to identify corrections needed. All ISP?s will be revised to include the correct support staff and their titles for each area needed in the ISP. This will include clarification of all facility roles, titles, and support instructions to ensure the ISP includes correct indications of support provisions by the appropriate employee or service provider and what steps should be taken by staff to do so appropriately. Part 2-The Administrator and ALF Coordinator reviewed the resident 2?s ISP regarding the use of a CPAP Machine and identification of known allergies. The Administrator verified the current known allergies and updated the ISP to reflect all know allergies as required. The Administrator updated Resident 2?s ISP to allow give further detail and instructions regarding his use of the CPAP machine, who will support him, and how support will be provided. The Administrator and ALF Coordinator communicated all ISP changes to all applicable employees. The Administrator will ensure that any new ISPs or changes to ISPs in the future include all needed elements as noted in standard.
Standard #:	22VAC40-73-550-F
Description:	Based on resident record review, the facility failed to ensure that the rights and responsibilities of residents contained the name and telephone number of the appropriate regional licensing supervisor of the department. EVIDENCE: 1. The Rights and Responsibilities of Residents of Assisted Living Facilities form for residents 1 and 2, dated 03/04/2021, indicated that the regional licensing administrator is Jennifer Stokes, with telephone number 540-589-5216; however, the correct regional licensing administrator is Nancy Hunter, with telephone number 540-309-2796.
Plan of Correction:	The Administrator reviewed the current Rights and Responsibilities form being used in the Facility to identify other potential errors. The current form was updated to reflect the appropriate licensing personnel as noted in the violation summary immediately. The Administrator and ALF Coordinator will meet with each resident to ensure they review and sign the updated Rights and Responsibilities form. The Administrator will ensure that any future changes to regional licensing supervisors be updated on all applicable forms within 24 hours of notice.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, the facility failed to ensure that physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall identify the diagnosis, condition, or specific indications for administering each drug. EVIDENCE: 1. Current physician orders for resident 1 did not include a diagnosis, condition, or specific indication for administering the following medications: Colace 100 mg oral capsule, Atorvastatin 20 mg tab, Haloperidol 10 mg tab, Lamotrigrine 25 mg tab, Olanzapine 20 mg disintegrating tab, and Olanzapine 10 mg disintegrating tab. 2. Current physician orders for resident 2 did not include a diagnosis, condition, or specific indication for administering the following medications: Zoloft 100 mg tab, Trazodone 50 mg tab, Lithium Carbonate 300 mg tab, Buspirone 10 mg tab, and Bupropoin HCL XL 30 mg tab.
Plan of Correction:	The Administrator and ALF Coordinator reviewed 22VAC40-73-(6)-650-B, the noted violations, and referenced resident?s current physician orders. The Administrator contacted the resident?s physician and requested new orders for the noted medications to include all needed information as noted in the violation. (05/06/2021 Dr. E Crossroads CSB via telephone) The Administrator will ensure the updated orders are filed in the resident record and MAR upon receipt. The Administrator and ALF Coordinator reviewed the physician orders on hand for each resident to ensure all orders include all required elements and information per the noted standard. All future physician orders received will be reviewed by the Administrator, ALF Coordinator, or Healthcare Oversight Nurse to ensure all information is present prior to placing in the resident?s record or MAR. The Administrator and ALF Coordinator will conduct monthly audits of all physician orders and MAR Records to prevent future violations. The Health Care Oversight Nurse will review the current Medication Management Plan with all RMAs during their annual medication refresher training being held on 05/17/2021 with each RMA.
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review, the facility failed to ensure that a sworn statement or affirmation (SD) was completed for all applicants for employment. EVIDENCE: 1. Staff 1, date of hire 10/01/2020, completed the SD after employment on 10/13/2020.
Plan of Correction:	The Administrator and Human Resource Coordinator reviewed 22VAC40-90-(BC2)-30-B and the current forms being utilized with all applicable job posting/hiring systems, such as INDEED, that were put in place during the COVID-19 pandemic. The SD form has been added to all initial application processes and forms to ensure applicants complete upon application as required by noted standard. The administrator and Human Resource Coordinator will review all methods of application resources such as INDEED monthly to ensure the SD form is available to all applicants and included in all other application packets that may be used.