VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Inspirit Hilltop Operator LLC
111 Denny Lane
Winchester, VA 22603
(540) 667-5323

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: July 6, 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 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

Comments:

A renewal inspection was initiated on 07/09/21 and concluded on 08/17/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 42. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, healthcare oversight, outside inspections, criminal history report, activities calendar and staff schedules submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 07/21/21. An exit interview was conducted with the Administrator and Director of Nursing on the date of inspection, 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-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on review of staff records, the facility failed to ensure direct care staff received eighteen hours of annual training as required. EVIDENCE: 1) The submitted record for staff #5 hired on 03/05/20 included a certificate of one hour training in Infection Control dated 03/11/20.
Plan of Correction:	Resident Wellness Director, Resident Care Director or designee will ensure that required training is complete for appropriate staff members. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-210-C
Description:	Based on review of staff records, the facility failed to ensure the required annual eighteen hours of training started no later than 60 days after employment. EVIDENCE: 1) The submitted record for staff #3 hired on 01/15/21 did not contain documentation of any training received since employment. 2) The submitted record for staff #4 hired on 02/18/2 did not contain documentation of any training received since employment.
Plan of Correction:	Resident Wellness Director, Resident Care Director or designee will ensure that required training is started for appropriate staff members no later than 60 days after employment. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-250-C
Description:	Based on review of staff records, the facility failed to ensure the staff record include required documentation. EVIDENCE: 1) The record submitted by the facility for staff #3 did not include documentation of medication aide registration and documentation of orientation. 2) The record submitted by the facility for staff #4 did not include documentation of completion of direct care staff training and documentation of orientation. 3) The record submitted by the facility for staff #5 did not include documentation of medication aide registration.
Plan of Correction:	Resident Wellness Director, Resident Care Director, Business Office Manager, Executive Director or designee will ensure required documents are in staff records. Executive Director, Business Office Manager or designee will complete an audit of all staff records to ensure compliance.
Standard #:	22VAC40-73-250-D
Description:	Based on review of staff records, the facility failed to ensure a current Tuberculosis screening form consistent with or published by the Virginia Department of Health is on file as required. EVIDENCE: 1) The facility "Mantoux Tuberculin Skin Test Record" form is dated 03/04/20.
Plan of Correction:	Resident Wellness Director, Resident Care Director or designee will ensure that the Tuberculosis Screening is on file as required. Business Office Manager with the support of Resident Wellness Director, Resident Care Director or designee will ensure a current Tuberculosis Screenings is on file in staff records. Business Office Manager will audit staff records to ensure compliance.
Standard #:	22VAC40-73-270-2
Description:	Based on documentation review, the facility failed to ensure restraint training provided included all components as required. EVIDENCE: 1. Documentation submitted by the facility for restraint training indicates "Therapy In-service: Transfers/Lap Belt/Gait belt" and contains signature of staff for 04/07/21 2. Documentation submitted by the facility for restraint training includes only signature of staff for 05/31/21, 06/01/21, 06/04/21 and 06/06/21. 3. Documentation submitted by the facility did not the training included information, demonstration, and experience in proper techniques for applying and monitoring restraints; skin care appropriate to prevent redness, breakdown and decubiti; active and active assisted range of motion to prevent contractures; observing and reporting signs and symptoms that may be indicative of obstruction of blood flow in extremities; turning and positioning to prevent skin breakdown and keep the lungs clear; provision of sufficient bed clothing and covering to maintain a normal body temperature; provision of additional attention to meet the physical, mental, emotional, and social needs of the restrained resident; awareness of possible risks associated with restraint use and methods of eliminating such risks.
Plan of Correction:	Resident Wellness Director, Resident Care Director or designee will ensure that restraint training is complete for appropriate staff members. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-290-B
Description:	Based on observation, the facility failed to develop and implement a procedure for posting the name of the current on-site person in charge. EVIDENCE: 1) During a walk-through of the facility, there was no visible posting of the current on-site person in charge.
Plan of Correction:	Executive Director or designee will develop and implement a procedure for posting the name of the current on-site person in charge. Executive Director will monitor weekly to ensure compliance.
Standard #:	22VAC40-73-325-A
Description:	Based on review of residents' records, the facility failed to ensure a fall risk rating was completed and on file as required. EVIDENCE: The submitted record for residents #1, #2 and #3 did not include a completed fall risk rating.
Plan of Correction:	Resident 1 Fall Risk Rating was completed on 3/30/21. Resident 2 Fall Risk Rating was completed on 3/29/21. Resident 3 Fall Risk Rating was completed on 04/01/21. However, the former Executive Director failed to produce these documents at the time
Standard #:	22VAC40-73-450-C
Description:	Based on review of residents' records, the facility failed to have a comprehensive Individualized Service Plan (ISP) that includes the assessed needs of the resident. EVIDENCE: 1) The UAI for resident #1 dated 03/19/21 indicates resident is disoriented to person, place and time on occasion. The ISP dated 03/19/21 indicates resident is oriented to time and place all of the time. 2) The UAI for resident #1 dated 03/19/21 indicates medication is administered by professional nursing staff. The ISP dated 03/19/21 indicates medication is administered by Registered Medication Aide (RMA). 3) The UAI for resident #2 dated 06/25/21 indicates resident is disoriented to person, place and time all the time. The ISP dated 06/25/21 indicates resident is disoriented to person, place, time and situation; there is no description of interventions in place. 4) The UAI for resident #2 06/25/21 indicates resident has disruptive behavior. This is not indicated on the ISP dated 06/25/21. 5) Resident #2 has an order for a lap belt for support effective 01/12/21. This is not indicated on the ISP dated 06/25/21. 5) Based on documentation review, resident #3 is receiving home health services and wound care. These are not indicated on the ISP dated 04/30/21. 6) The UAI for resident #3 dated 06/21/21 indicates physical and mechanical assistance is needed with transfers. The ISP dated 04/30/21 indicates resident is independent with transferring. 7) The UAI for resident #3 dated 06/21 21 indicates resident is disoriented to person, place and time all of the time. The ISP dated 04/30/21 indicates situation, person, place and time all of the time. 8) The UAI for resident #3 dated 06/21/21 indicates resident has behaviors of wandering constantly and calling out frequently. This is not indicated on the ISP dated 04/30/21. The section for activities indicates another resident's name. 9) Resident #3 has an order dated 06/11/21 for a lap belt for safety. The ISP dated 04/30/21 indicates the lap belt is used for support while resident is in wheelchair.
Plan of Correction:	Resident Wellness Directors with the support of Resident Care Director or designee will ensure that all assessed needs of residents are included in the ISP. An audit of all ISP?s will be completed to ensure compliance. ISP?s will be update accordingly to ensure compliance. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-450-D
Description:	Based on review of residents' records, the facility failed to ensure the Individualized Service Plan (ISP) includes the services provided by hospice. EVIDENCE: 1) The ISP for resident #2 does not identify the services provided by the hospice agency. 2) The hospice plan of care dated 06/28/21 for resident #2 indicates service of bathing twice weekly and for resident to have small frequent feedings and sips of fluid as tolerated. This is not indicated on the ISP.
Plan of Correction:	Resident Wellness Directors with the support of Resident Care Director or designee will ensure that all assessed ISP?s includes services provided by hospice. An audit of all ISP?s will be completed to ensure compliance. ISP?s will be update accordingly to ensure compliance. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-450-E
Description:	Based on review of residents' records, the facility failed to ensure the Individualized Service Plan are signed and dated by the resident or legal representative. EVIDENCE: The ISPs submitted for residents #1, #2 and #3 do not include the resident or legal representative's signature.
Plan of Correction:	Resident Wellness Director, Resident Care director or designee will ensure that ISP?s contain required signatures. An audit of all ISP?s will be completed to ensure compliance. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-660-B
Description:	Based on record review, the facility failed to ensure the UAI indicates resident is capable of self-administering medication and is permitted to keep medication in room. EVIDENCE: 1) The UAI dated 03/19/21 indicates medication for resident #1 is administered by professional nursing staff and resident is disoriented to person, place and time on occasions. 2) The June and July 2021 Medication Administration Record (MAR) for resident #1 has an order for Creon Capsules indicating resident may self-administer and keep at bedside. The order indicates medication is to be administered before breakfast, lunch, supper and at bedtime.
Plan of Correction:	Resident Wellness Director, Resident Care Director or designee will ensure that the UAI is completed accurately to include the section that indicates resident is capable of self-administering medication and is permitted to keep medication in room. Executive Director will provide oversight to ensure compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on document review and observation, the facility failed to administer medication in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1) Page 122 of the Virginia Board of Nursing Medication Aide Curriculum for Registered Medication Aides shows #3 Read the Medication Administration Record (MAR) and compare with the Health Care Professional's (HCP) orders; #4. Get the medication container from the cart/cabinet and read the label to verify the right client. 2) Staff #6 administered Tramadol HCL 50mg to the wrong resident. 3) During an audit of the medication cart, the LI observed 27 tablets in the Tramadol HCL 50mg packet for resident #1. The narcotic count sheet indicated 26 tablets. 4) During and audit of the medication cart, the LI observed 22 tablets in the Tramadol HCL 50mg packet for resident #3. The narcotic count sheet indicated 23 tablets. 5) The June 2021 Medication Administration Record (MAR) for resident #1 indicates the resident refused the 9:00am scheduled dose of Novolin on 06/01/21, 06/04/21, 06/06/21, 06/07/21, 06/09/21, 06/14/21, 06/15/21, 06/16/21, 06/25/21, 06/26/21 and 06/27/21 and 07/13/21; however there is no documentation to show this was reported to the prescribing physician. 6) The June 2021 Medication Administration Record (MAR) for resident #1 indicates the resident refused the 6:00pm scheduled dose of Acetaminophen on 06/12/21, 06/17/21, 06/18/21, 06/22/21, 06/23/21, 06/24/21, 06/26/21, 06/30/21 and 07/01/21; however there is no documentation to show this was reported to the prescribing physician. 7) The June 2021 Medication Administration Record (MAR) for resident #1 indicates the resident refused the 12:00pm scheduled dose of Acetaminophen on 06/09/21, 06/26/21 and 06/27/21 and 07/07/21; however there is no documentation to show this was reported to the prescribing physician. 8) The June 2021 Medication Administration Record (MAR) for resident #1 indicates the resident refused the 12:00am scheduled dose of Acetaminophen on 06/01/21 06/05/21, 06/07/21, 06/08/21, 06/10/21, 06/14/21, 06/15/21, 06/16/21, 06/17/21, 06/28/21 and 06/29/21; however there is no documentation to show this was reported to the prescribing physician. 9) Based on review of MAR for resident #3, Tamoxifen was not available for administration on 06/13/21 and 06/28/21 at 7:00pm. 10) Based on review of MAR for resident #3, Phenazopyrid was not available for administration on 07/09/21 9:00pm and 07/10/21 at 9:00am. 11) Based on review of MAR for resident #3, Trazadone was administered for anxiety/agitation on 06/29/21 at 6:08pm, 07/01/21 at 5:58pm, 07/02/21 at 4:08am, and 07/03/21 at 12:44pm; results documented for each administration "not effective." There is no documentation of follow-up.
Plan of Correction:	Resident Wellness Director with the support of Resident Care Director or designee will implement the medication management plan methods to include but not limited to, to ensure compliance: ? Reporting refusals to prescribing physicians. ? Appropriate follow-up for medications that are not effective. Medications will be administered in accordance with physicians? instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the VA BON. Resident Wellness Director with the support of Resident Care Director or designee will complete routine medication audits to ensure compliance.
Standard #:	22VAC40-90-40-B
Description:	Based on review of staff records, the facility failed to ensure a criminal history report was obtained prior to the 30th day of employment. EVIDENCE: 1) Staff #1 was hired on 05/15/19. The criminal history report is dated 06/01/21. 2) Staff #2 was hired on 02/15/21. The criminal history report is dated 12/07/20.
Plan of Correction:	Business Office Manager or designee will ensure that facility obtains a criminal history report prior to the 30th day of employment. Executive Director will provide oversight to employee files to ensure compliance.