VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Dunlop House
235 Dunlop Farms Boulevard
Colonial heights, VA 23834
(804) 520-0050

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: March 10, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 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. Responding to allegations made against the facility a complaint investigation was initiated on 03/10/2021 and concluded on 07/19/2021. The licensing inspector emailed the administrator a list of documents required to complete the investigation. The evidence gathered during the investigation supported the determined non-compliance(s) with applicable standards or law and determined the complaint to be valid. Violations were documented and are on the violation notice issued to the facility. The inspector conducted interviews with facility staff and others and reviewed facility records. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions please feel free to contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-150-C
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the administrator failed to be responsible for the general administration and management of the facility. This shall include responsibility for: Maintaining compliance with applicable laws and regulations and implementing all policies and procedures, and services required by this chapter and ensuring the development, implementation, and monitoring of an individualized service plan for each resident. Evidence: Resident #1- Documented date of admission 06/11/2019; Documented date of discharge 02/1/2021 The complainant reported that resident #1 was discharged from a local hospital on hospice care back to the facility on 01/25/2021. Regarding the resident?s 01/25/2021 hospital discharge the complainant also reported that ?they (the facility) failed to contact me to update and create (resident #1 identified) care plan.? The facility?s Hospice Policy noting a revised date of 02/01/2019 that was submitted for the inspector?s review from the facility Administrator via email dated 04/14/2021 notes under the heading Procedure #3: ?After the resident and their representative make their choice of a preferred hospice vendor, the facility social worker or designee will assist the resident in contacting that vendor in order to set up the appointment for the hospice assessment.? During interviews the facility Administrator acknowledged that the resident does have a Power of Attorney (POA) The identified hospice agency?s agreement signed and dated by the facility Administrator on 01/23/2021 notes on page 3/14 under the heading Notification of Services ?Facility shall fully inform Hospice Patients of Facility Services and Uncovered Items and Services to be provided by Facility.? The signed Hospice agreement also notes on page 4/14 under the heading Design of Plan of care: ?In accordance with applicable federal and state laws and regulations, Facility shall coordinate with Hospice in developing a Plan of Care for each Hospice Patient. Hospice retains primary responsibility for development of the Plan of Care.? In response to the inspector?s inquiry whether the facility contacted the Hospice agency or the resident?s Power of Attorney (POA) to discuss and develop a plan of care prior to or after the resident?s hospital discharge back to the facility; the facility Administrator responded in part via an email dated 04/14/2021 ?No community involvement. Discussion was held in hospital between family and hospital staff.? The 06/18/2020 Individualized Service Plan (ISP) for resident #1 was not updated per the resident?s assessed needs. The facility Administrator did not implement the facility?s hospice policy or the signed hospice agreement ensuring that the hospice agency, the facility and the resident?s Power of Attorney had discussed and updated a plan of care identifying each entity?s responsibility for ensuring that the assessed service needs of the resident would be carried out by facility staff.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-H
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that reassessments due to a significant change in the resident's condition, using the UAI, was utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: Resident #1: Documented date of admission 06/11/2019; Documented date of discharge 02/01/2021 The complainant reported that resident #1 was sent out from the facility on 01/14/2021 to the hospital for emergency medical intervention; was subsequently admitted and then discharged back to the facility on 01/25/2021 after an eleven day hospital stay. During interviews the complainant also reported that resident #1 was discharged back to the facility on hospice care and that the facility did not asked her to participate in the assessment process, which would have provided a clear picture of (resident #1 identified) current health needs or wishes. Interviews conducted with the facility Administrator, facility staff #1 and the review of facility records to include the resident?s 01/25/2021 hospital discharge documentation that was submitted for the inspector?s review,- revealed that resident #1 was not receiving hospice services prior to the resident?s hospital admission on 01/14/2021. Facility records submitted for the inspector?s review also noted that the facility conducted the most recent Uniform Assessment Instrument (UAI) on resident #1 on 06/10/2020; seven months prior to the resident?s 01/14/2021 hospitalization. Facility records that were submitted by the facility for the inspector?s review and interviews conducted with the facility Administrator indicates that at the time that the 01/23/2021 hospice agreement was signed the facility was aware of the resident?s change in condition. Upon request the facility did not submit for the inspector?s review documentation that the facility conducted a reassessment on resident #1 prior to or since the resident?s hospital discharge back to the facility to ensure that the assessed needs of the resident would be carried out by facility staff.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-D
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident and that the services provided by each is included on the individualized service plan. Evidence: Resident #1: Documented date of admission 06/11/2019; Documented date of discharge 02/01/2021 For example the resident?s HOSPICE CERTIFICATION AND PLAN OF CARE document with a faxed date of 01/27/2021 that the facility submitted for the inspector?s review notes in part on page 3/5 ?Home health aide service for assistance with personal care, hygiene and activities of daily living? (ADL). The facility did not include this hospice service on the resident?s facility care plan. While the resident?s most recent 06/18/2020 Individualized Service Plan (ISP) that the facility submitted for the inspector?s review does include a handwritten entry dated 01/25/2021 that notes that the resident will receive hospice services the ISP does not identify the specific services that the hospice agency identified in their plan of care that they would be responsible for. Facility staff #1 clarified that 01/27/2021 is the fax date noting when the facility received the resident?s HOSPICE CERTIFICATION AND PLAN OF CARE document.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that Individualized service plans are updated as needed for a significant change of a resident?s condition. The update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: Resident #1: Documented date of admission 06/11/2019; Documented date of discharge 02/01/2021 For example prior to the resident?s 01/14/2021 hospitalization the facility assessed the resident on 06/10/2020 as needing mechanical assistance only (walker/wheelchair) for Ambulation. The resident?s hospice care plan that was submitted for the inspector?s review notes that resident #1 was assessed by the hospice agency as needing two person assist for bed mobility and transfers; indicating a significant change in the resident?s condition. The resident was assessed by the facility on 06/10/2020 as being independent with continence care. The hospice agency documented that the resident is totally dependent on facility staff to provide incontinence care. The hospice agency assessed the resident as having aspiration problems, malnutrition, dehydration, respiratory failure. The hospice care plan also notes that the resident ?will tolerate PO trials without clinical indicators of aspiration given minimal cues within 7 day?. The resident?s most recent Individualized Service Plan (ISP) dated 06/18/2020 that was submitted for the inspector?s review was not updated to note that based on the assessment of the hospice agency significant changes had occurred in the resident?s condition.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-B
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the administrator failed to ensure care provision and service delivery was resident-centered to the maximum extent possible and included the residents? participation in decisions regarding the care and services provided to him. Evidence: Resident #1: Documented date of admission 06/11/2019; Documented date of discharge 02/01/2021 The complainant reported that the facility did not contact her to discuss the current health status of the resident or to assist with the development of an updated Individualized Service Plan (ISP). The investigation revealed that at the time that the facility Administrator signed the hospice agreement on 01/23/2021; the facility was aware that the resident had an assigned Power of Attorney (POA). The facility Administrator reported that the facility had no involvement with ensuring that the resident?s POA and hospice agency was involved with developing and updating the resident?s facility ISP; stating ?No community involvement. Discussion was held in hospital between family and hospital staff.? However, the review of the facility?s hospice policy and at the time that the facility Administrator signed the hospice agreement the facility Administrator indicated an acknowledgement and an understanding of the facility?s and the hospice agency?s responsibilities regarding the assessed needs of the resident and that requires that the resident?s POA be included in the decisions regarding care and services for resident #1. Upon request the facility did not submit for the inspector?s review facility documentation that an ISP was developed based on the assessed needs identified by the hospice agency or that input regarding the resident?s care was obtained from the resident?s POA.
Plan of Correction:	Not available online. Contact Inspector for more information.