VIRGINIA DEPARTMENT OF SOCIAL SERVICES

DLM Corporation
3502 Chamberlayne Avenue
Richmond, VA 23227
(804) 357-6743

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: April 2, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 4/2/2021 and concluded on 4/16/2021. A complaint was received by the department regarding allegations in the areas of resident supervision and oversight, resident accommodations, resident care and incident reporting. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator and his designee a list of documentation required to complete the investigation. The evidence gathered during the investigation supported non-compliance with standards or law, and violations in the areas of resident supervision and oversight, resident care and incident reporting were issued. Violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-50-A
Complaint related:	No
Description:	Based on a review of the disclosure statement for one resident (#1) during a complaint investigation, the statement: (1) did not correctly address all of the elements required by standard 22VAC40-73-50 and (2) did not include a required element. Evidence: 1. Section I - Two licensed facilities are listed under ?Name of the Facility?. It also list the name of the owner as the licensee, the licensee is a corporation (corporation A). 2. Section II -The statement did not disclose the amount of the base fee, the statement note ?None?. The statement did not disclose accommodations, services, care included in the base fee, the statement note ?This will be in your Contract Agreement?. 3. Section III ? The statement did not disclose the criteria for discharge from the facility, the statement note ?This is located in the policy and procedure book?. 4. Section IV -The frequency of activities on the statement was not in compliance with standard 22VAC40-73-520.E. The statement note the frequency of activities as ?weekly?, the required frequency is ?daily?. 5. Section V ? The number of staff per shift is documented as ?1?. The administrator is not listed or included in the number of staff. 6. Section VII - The statement submitted for resident # 1 did not include Section VII which addresses whether or not the facility has an on-site emergency power source for the provision of electricity during interruption of normal electric power supply.
Plan of Correction:	The facility will use the current disclosure statement and the following will be corrected: 1. Section I. The licensee will list the DLM Corporation on the form. 2. Section II. The facility base rent of $1,420.00 will be added. 3. Section III. The criteria for discharge from the facility will be added. 4. Section IV. A statement will be added. The facility offers a range of physical, social, creative, cognitive, and musical activities daily and utilizes available community resources. 5. Section V. The facility will update the number of staff per shift to include the administrator. 6. Section VII. The facility has added that it does have an onsite emergency power source for the provision of electricity during the interruption of normal electric power supply..
Standard #:	22VAC40-73-50-B
Complaint related:	No
Description:	Based on review of the disclosure statement for one resident, the facility failed to document written acknowledgment of the receipt of the disclosure by the resident's legal representative. Evidence: On 12/3/2020 resident # 1 was appointed a guardian ad litem by the court. The disclosure statement submitted by the facility documented the resident?s acknowledgement of receipt by initials of the resident. There was no written acknowledgement of receipt of the statement by the legal representative for resident # 1.
Plan of Correction:	An attorney called the facility seeking placement for resident #1 because he had no place to live. The resident was being discharged from the Henrico County jail. The attorney did not identify himself as the legal guardian. There was no reason to follow-up because we were unaware of the guardianship. .
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on receipt of an allegation regarding a major incident, the facility failed to report to the regional licensing office within 24 hours a major incident that negatively affected the life, health, safety, and welfare of a resident. Evidence: A citizen's report of a resident's death was received by a state delegate and forwarded to the central region licensing office on 4/2/2021. During a telephone call to the facility's administrator/licensee on 4/2/2021, the resident's death was confirmed. It was learned through interviews with the citizen and a Richmond city police detective that on 3/11/2021 resident # 1 was discovered by the citizen laying on the ground at a bus stop approximately one block from the facility in distress. The citizen called 911 and the resident was transported to a local emergency room. Resident # 1 died. Another resident (#2) was arrested at the facility in regards to an alleged assault of resident # 1. A report of the death of resident # 1 and a report of the arrest of resident # 2 was not received by the central region licensing office within 24 hours of the incident.
Plan of Correction:	The facility did report the fall to licensing verbally and in writing incident report) on 3/11/2021. In the past the facility has notified licensing within 24 hours of any major incident. This situation was an out of the ordinary occurrence. We have policies and procedures regarding incidents but as this situation was under police investigation, we were not getting a lot of information. Because the police were not communicating with the facility directly, we were not aware of the death of resident #1. A detective disclosed that the resident had passed at the end of an interview with one of the residents at the facility on 4/2/2021. It seems that the altercation started on the van that transports the residents to and from the day support program. If the van driver had made the facility staff aware of what transpired during the commute, we would have been in a better position to de-escalate the situation. We have since requested that the transportation company notify the facility when they drop off the residents if there were any problems or concerns during their transport to and from the day support program.
Standard #:	22VAC40-73-70-C
Complaint related:	Yes
Description:	Based on receipt of an allegation regarding a major incident, the facility failed to submit a written report of a major incident to the regional licensing office within seven days from the date of the incident. Evidence: A verbal report of a resident fall was received by the central region licensing office from the facility's administrator/licensee on March 11, 2021. A written report dated 3/11/2021 was received by fax on 4/5/2021, more than seven days from the date of the incident.
Plan of Correction:	An incident report was scanned to the central licensing on 3/11/2021 about resident #1 falling. No additional information was available at the time
Standard #:	22VAC40-73-320-A
Complaint related:	No
Description:	Based on a review of the physical examination for two residents, the physical examination for one resident that was completed within 30 days preceding admission did not address two of the conditions or care needs prohibited by 22VAC40-73-310 H. Evidence: The admission physical examination for resident # 1 dated 12/20/2021 did not address: (1) psychotropic medications without appropriate diagnosis and treatment plans (2) or continuous licensed nursing care. The two areas that address these conditions were not completed by the physician.
Plan of Correction:	In the future the administrator will ensure that the doctor addresses all the prohibited conditions on the physical examination form. The form will be reviewed by the administrator prior to the resident's admission to ensure it is complete..
Standard #:	22VAC40-73-380-A
Complaint related:	Yes
Description:	Based on a review of the file for resident # 1 during a complaint investigation. it was found that the facility failed to secure copies of current legal documents that show proof of each legal representative's authority to act on behalf of the resident and that specify the scope of the representative's authority to make decisions and to perform other functions. Evidence: The uniform assessment instrument for resident # 1 dated 12/20/2021 documented the appointment of a guardian ad litem. The licensing inspector confirm the appointment through a telephone interview with the guardian ad litem. A copy of current legal documents that show proof of the legal representative's authority to act on behalf of the resident and that specify the scope of the representative's authority was not found during the review of file documentation submitted for resident # 1.
Plan of Correction:	As stated previously, an attorney called the facility seeking placement for resident #1 because he had no place to live. The resident was being discharged from the Henrico County jail. The attorney did not identify himself as the legal guardian. There was no reason to follow-up because we were unaware of the guardianship.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on a review of the service plans for two residents, the plan for one resident did not include all identified needs of the residents. Evidence: The quarterly mental health progress review for resident # 2 (dated 10/2020 to 1/2021) identified a fall risk prevention and safety plan and feelings of wanting to harm self and others daily along with verbal aggression toward peers. The ISP for resident # 2 did not address the supports put in place at the facility to address these needs.
Plan of Correction:	The ISP for resident #2 states that the resident does wear the same outfit for days. The resident refuses to change clothes when asked by staff. Due to his mental illness, he does not feel he needs to bathe or change his clothes daily. All residents have shower days assigned to them. If the resident refuses to shower more than 3 times in a month the psychiatrist will be notified. The facility will also check with the day support program to assist with developing a plan of action.
Standard #:	22VAC40-73-460-A
Complaint related:	Yes
Description:	Based on an allegation received regarding a resident's death and an investigation of the allegation, the facility failed to assume general responsibility for the well-being of residents in care. Evidence: 1.The staff person in charge (staff # 2) reported the following during an interview with the licensing inspector on 4/5/2021: (1) resident # 1 entered the facility yelling "call the police, call the police"; (2) he was informed that two residents were involved in an altercation; (3) he tried to calm resident # 1; (4) resident # 2 was asked to stay outside the facility; (5) resident # 1 went to his room, when checked on 15 minutes later, resident # 1 could not be found; (6) he observed resident # 1 laying on the ground at a bus stop; (7) he called the ambulance. 2. The lack of vigilance in supervision of the two residents involved in the altercation by facility staff placed both residents at risk of health safety. and welfare. 3. Resident # 1 was hospitalized shortly after the altercation and died while in the hospital. 4. Resident # 2 was arrested in connection with the altercation/death of resident # 1. The Richmond City Incident Reports list the charge as "murder, non-negligent manslaughter, with hands/fist feet".
Plan of Correction:	On 3/11/2021 resident #1 entered the facility yelling and screaming to call the police. He showed no signs of a physical distress. Both resident #1 & #2 were upset. Staff #1 told resident #2 to go outside and he called the resident's father to calm him down. Resident #2 never entered the residence again. Resident #1 calmed down and had dinner. Because resident #1 still wanted to continue the argument with resident #2 he was asked to go to his room. Staff #1 was unaware that resident #1 left the facility. When the staff went to check on resident #1, he discovered he was missing. The staff member looked out the door and saw resident #1 down the street laying on the ground. He called an ambulance. There was approximately 50 minutes from the time resident #1 & #2 came home from the day support program. Since then, another resident reported he was walking down the street behind resident #1 and saw him stumble and fall to the ground.
Standard #:	22VAC40-73-460-I
Complaint related:	Yes
Description:	Based on a review of the a mental health provider's quarterly review of the ISP, the facility failed to assume general responsibility for the well-being of the one resident in the area of clean clothing and body odors related to hygiene. Evidence: The mental health quarterly review of the ISP for resident # 2 documented " client often wears the same outfits for days at a time and body odors being noted this quarter." The review further documented that client self reported "I do not bathe daily, I don't feel like it" "
Plan of Correction:	The ISP for resident #2 states that the resident does wear the same outfit for days. The resident refuses to change clothes when asked by staff. Due to his mental illness, he does not feel he needs to bathe or change his clothes daily. All residents have shower days assigned to them. If the resident refuses to shower more than 3 times in a month the psychiatrist will be notified. The facility will also check with the day support program to assist with developing a plan of action..
Standard #:	22VAC40-73-680-H
Complaint related:	No
Description:	Based on a review of medication administration records (MARs) for two residents, the facility failed to accurately document medication administered to one resident. Evidence: The central region licensing office was notified verbally by the administrator and in a written incident report that resident # 1 was hospitalized due to a fall on 3/11/2021. The incident report documented the time of the incident as 3:40 pm and that the resident was transported to the hospital. Resident remained in the hospital and did not return to the facility. Staff documented the administration of 4 medications (risperidone, atorvastatin, levetiracetam and depakote) as being administered at 8 pm on 3/11/2021 and one medication (levetiracetam) as being administered at 5 pm on 3/11/2021.
Plan of Correction:	Resident was hospitalized on 3/11/2021 at 3:40 pm. The MAR reflects he was administered one medication at 5PM and 4 medications at 8PM.