VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Huntington
11143 Warwick Boulevard
Newport news, VA 23601
(757) 223-0888

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: July 19, 2021 , July 22, 2021 and July 23, 2021

Complaint Related: No

Areas Reviewed:

Part III- PERSONNEL Part IV- STATTING AND SUPERVISION Part V- ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS Part VI-RESIDENT CARE AND RELATED SERVICES Part IX- EMERGENCY PREPAREDNESS Part X- Mixed Population Criminal Background Checks Sworn Disclosure

Comments:

A renewal inspection was initiated on 7-19-21 and concluded on 7-23-21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 15. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 2 resident records, 2 staff records, activities calendar, new hire criminal background check and sworn disclosure, staff schedules, fire and health inspection, emergency fire drills, nutrition/ pharmacy and healthcare reports submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7-23-21. An exit interview was conducted with the Administrator on 7-22-21 and the Director of Nursing on 7-23-21 on the date of inspections, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based on record review and staff interview, the facility failed to ensure within four months of starting date of employment, a direct care staff attended six hours of training in working with individuals who have a cognitive impairment. Evidence: 1. Staff #4?s record documented staff?s date of hire as 1-11-21. Staff?s training record documented staff attended 3.0 hours of cognitive training within four months. 2. Staff #1 and #3 acknowledged, staff #4?s training record did not document 6 hours within 4 months of hire.
Plan of Correction:	1. Staff #4's training will be updated to include 6 hours of training in working with resident's with cognitive impairment. 2. New hire direct care staff trainings will be audited for completeness of required training within the first four months of employment. Staff who are responsible for direct care staff training were re-educated on the training requirements for direct care staff within four months of employment. 3.The Director of Nursing/ designee will audit new hire direct care staff training monthly for three months to ensure the training requirements are being met. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to theQuality Assurance committee.
Standard #:	22VAC40-73-210-B
Description:	Based on record review and staff interview, the facility failed to ensure a licensed direct care staff attended at least 12 hours of annual training. Evidence: 1. Staff #5?s annual training record submitted documented 9.5 hours of annual training; staff?s date of hire was documented as 3-4-2018. 2. Staff #1 acknowledged, staff #5?s record did not include 12 hours of annual training.
Plan of Correction:	1. Staff #S's training is now up to date for this year of annual training. 2. Direct care staff trainings will be audited for completeness within their training year. Staff who are responsible for ensuring staff training is completed annually were re-educated on the training dates being from their date of employment. 3. The Director of Nursing/ designee will audit annual staff training for direct care staff members monthly for three months to ensure all staff training requirements are being met. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-440-D
Description:	Based on record review and staff interview, the facility failed to ensure the Uniformed Assessment Instrument was completed as required for two residents. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) conducted 4-15-21 and 5-15-21 was not signed and dated by the assessor for 5-15-21. 2. Resident #2?s UAI conducted on 10-26-20 was not signed and dated by a reviewer. 3. Staff #1 and #3 acknowledged on 7-22-21, resident #1 and #2?s UAI were not signed and dated as required.
Plan of Correction:	1.The UAI for resident #1 and resident #2 were updated to include the signature and date of the assessor. 2. UAIs will be audited to ensure completeness for all residents to include a signature and date. The nursing manager was re-educated on completeness of the UAI to include the signature and date when a second assessment is completed. 3. The Director of Nursing/ designee will audit all UAIs that are due that month monthly for three months to ensure completeness, to include signatures and dates. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-520-E
Description:	Based on document review and staff interview, the facility failed to ensure the activity calendar included information to demonstrate that at least 14 hours or activity is provided each week Staff #1 acknowledged the activity calendar did not include the time/ duration of activities noted on the July 2021 Activity calendar.
Plan of Correction:	1. The August activity calendar has an added legend that uses symbols to indicate the duration of each activity. Every activity has a symbol next to the activity name that will allow one to easily know how long the program will last. 2. The activity calendar will be reviewed by the Administrator monthly to ensure the duration of each activity is indicated. Activity Director was educated on need for time/duration to be clearly denoted for each activity. 3. The Administrator/designee will conduct an activity calendar audit monthly for three months to ensure activity duration is clearly indicated on the calendar. Audit results will be reviewed for patterns and trends and findings will be reported to the Quality Assurance Committee.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition or specific indications for administering each drug. Evidence: 1. Resident #2?s, ?Physician?s order sheet for June 2021?, dated 6-20-21, Centrum Silver did not identify the diagnosis, condition or specific indications for administering. The documents noted, ?diagnosis exempt?. 2. On 7-22-21, staff #1 and #3 acknowledged, resident #2?s Centrum Silver did not indicate the diagnosis.
Plan of Correction:	1. The medication order for resident #2 was updated to include diagnosis. 2. Medication orders will be audited to ensure all orders have a diagnosis listed. All LPNs will be re-educated on ensuring they obtain a diagnosis from the provider for all medications that are ordered. 3. The Director of Nursing / designee will audit all Physician Order Sheets monthly for three months to ensure completeness and accuracy, to include a diagnosis. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.