VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chesapeake Place
1500 & 1508 Volvo Parkway
Chesapeake, VA 23320
(757) 548-0808

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: July 27, 2021 , July 28, 2021 , July 29, 2021 , Aug. 23, 2021 , Sept. 8, 2021 and Sept. 9, 2021

Complaint Related: No

Areas Reviewed:

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 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

A non-mandated monitoring inspection was initiated on 7-28-21 and concluded on 9-9-21. The administrator resident services director was contacted by telephone to conduct the investigation. The resident services coordinator reported that the census was 62. The inspector emailed the administrator and resident services director a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed seven resident records, four staff records, activities calendar, fire inspection, health inspection, pharmacy report and staff schedules submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7-29-21. An exit interview was conducted with the Administrator on 9-8-91 and 9-16-21, 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 with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1140-B
Description:	Based on record review and staff interview, the facility failed to ensure within four months of the starting date of employment in the safe, secure environment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meet the regulatory requirements. Evidence: 1. Staff #6?s record did not contain documentation of at least 10 hours of cognitive training since employment date of 12-22-20. 2. Staff #1 acknowledged during exit meeting on 9-8-21 and 9-16-21, staff?s record did not have documentation of required cognitive training.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-210-B
Description:	Based on record review and staff interview, the facility failed to ensure staff attend at least 18 hours of training annually. Evidence: 1.Staff #4?s record did not contain documentation of annual training. The staff roster provided and orientation training document noted staff?s date of hire as 12-31-19. 2. Staff #5?s record did not contain documentation of annual training. The facility orientation training document noted staff?s date of hire as 2-1-17. 3. Staff #1 acknowledged during exit on 9-8-21, staff did not have training hours. On 9-16-21, during final exit staff confirmed staff?s date of hire was the date noted in staff?s record and the staff roster.
Plan of Correction:	ED and BOM will audit staff training and keep log of all in-services to ensure staff of all departments are receiving required training
Standard #:	22VAC40-73-260-A
Description:	Based on record review and staff interview, the facility failed to ensure direct care staff maintain current certification in first aid. Evidence: 1. Staff #5?s first aid card was not provided for review. Staff #6?s first aid and cardiopulmonary resuscitation (CPR) cared was expired on 6-11-21. 2. Staff #1 started card needed to be printed. However, documents were not received with follow-up documents received on 9-9-21.
Plan of Correction:	RCC will conduct monthly CPR/First Aid certification classes for those staff members approaching expiration of their certification. Those without proper certification will be removed from schedule until time that their certification is up to date. BOM will track and notify staff member of mandatory upcoming classes and log participation. RCC will issue copy of certification to BOM and to staff member.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without a treatment plan. Evidence: 1. Resident #4?s record did not have a treatment plan for Lorazepam, documented on resident?s physician order sheet dated 6-16-21 and June 2021 medication administration record. 2. Resident #7?s record did not have a treatment plan for Clonazepam, documented on resident?s physician order sheet dated 4-27-21 and July 2021 medication administration record. 3. Staff #1 acknowledged on 9-8-21 and 9-18-21 during exit meeting, treatment plans were available for residents #4 and #7.
Plan of Correction:	RCD and RCC will conduct weekly chart audits to ensure treatment plans are received from physician for all residents who are prescribed psychotropic medications.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and staff interview, the facility failed to ensure the physical examination document included all required information. Evidence: 1. Resident #2?s physical examination dated 5-18-21 did not include resident?s blood pressure information. 2. Staff #1 acknowledged on 9-8-21 during exit meeting, information was not on the physical examination form.
Plan of Correction:	ED and RCD will review all Health and Physical forms are fully completed prior to admission to ensure all required information is state on residents H&P forms.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for seven residents. Evidence: 1. Resident #1?s uniformed assessment instrument (uai) dated 7-1-21 documented bathing, dressing, toileting and transferring as mechanical help/human help/ physical assistance. However, the individualized service plan (ISP) dated 7-1-21 documented direct care staff will provided the following: (a) bathing, ?Give encouragement to resident to bath self with wash cloth to physical limitations. Allow resident sufficient time to bath without feelings of being rushed?. (b) dressing, ?Allow sufficient time for dressing and undressing. Provide a consistent dressing routine to decrease confusion and encourage independence?. (c) toileting, ?Remind resident to use the toilet regularly. Report any changes in condition to physician and follow any orders?. (d) transferring documented as ?independent?. Resident?s uai also documented waling and stairclimbing as not performed, however, needs are not documented on the ISP. Mobility on the uai assessed as mechanical help; however, the ISP documented, ?Human Help: Physical Assist, Assist client with transportation to appointments. Remain with client during all appointments, speak with responsible party to solicit their assistance?. 2. Resident #2?s physical examination dated 5-18-21 documented resident allergic to Penicillin, this was not documented on resident?s ISP dated 6-3-21. Resident received physical therapy services from 6-17-21 through 7-14-21, this information was not documented on the ISP. 3. Resident #3?s uai dated 6-21-21 documented mobility as mechanical help/human help/supervision; however, the ISP dated 7-29-21 documented, ?Assist client with transportation to appointments?. Physical therapy and Occupational therapy documented did not include services provided. 4. Resident #4?s uai dated 7-6-21 documented resident is disoriented all spheres, all the time, however, the ISP dated 7-6-21 did not include this need. The resident?s use of incontinent products is not included on the ISP; resident incontinent both bowel and bladder. 5. Resident #5?s uai dated 7-1-21 documented resident?s behavior as appropriate, however, the ISP documented, ?Behavior-Appropriate; exhibits appropriate behaviors: is independent with behavior management?. 6. Resident #6?s record, clinical notes dated 6-29-21 documented resident receiving wound care, however, the ISP dated 7-1-21 did not include this service need. 7. Resident #7?s uai dated 7-8-21 documented medication administration by layperson and professional, however, the resident?s ISP dated 7-8-21 documented medication administration, ?Medication Administration: Administered by Professional Nursing Staff; RN, NP, PA, MD?. The resident was observed going the hallway in the facility with the following five medications in a souffle cup on the seat of a rollator walkway: Clonazepam, Gabapentin, Atenlol, Aspirin and a multivitamin.
Plan of Correction:	ED and RCD will review each UAI and ISP to 11/15/2021 ensure that are complete and accurately noting specifics of care needs for residents after each assessment and upon condition changes. ED and RCD will in-service all Med Techs to ensure knowledgeable of proper procedures of administering medications.
Standard #:	22VAC40-73-450-D
Description:	Based on record review and staff interview, the facility failed to ensure 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. The services provided by each shall be included on the individualized service plan (ISP). Evidence: 1. Residents #4 and #6? s record document residents are receiving hospice services, however, the resident #4?s individualized service plan (ISP) dated 7-6-21 and resident #6?s ISP dated 7-1-21 did not include the services provided by the hospice organization. 2. Staff #1 acknowledged during the exit on 9-8-21 and 9-16-21 that the residents? ISP did not document the hospice services.
Plan of Correction:	RCC will document ISP with all services provided by outside companies including Hospice and Therapy companies.
Standard #:	22VAC40-73-650-A
Description:	Based on record review and staff interview, the facility failed to ensure no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: 1. Resident #1?s records were requested as part of the sample review and received on 7-29-21 and 9-9-21. However, no signed and dated physician or prescriber?s orders were received. 2. Resident #5?s June 2021 medication administration record (MAR) documented on 6-9-21, prn Imodium was administered. However, the facility did not have a physician or prescriber?s order for the medication. 3. Resident #7?s July 2021 MAR documented Lidocaine patch to be placed on shoulder for 7 days, the MAR documented order 7-1-21 and stop 7-9-21. 4. Staff #1 acknowledged during the exit on 9-8-21 and 9-16-21 physician?s orders were not provided.
Plan of Correction:	RCD and RCC will indicate on MAR when medications is received from pharmacy and document when medication is to be started and finished based on receipt of medication from pharmacy.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the facility failed to ensure the physician and or prescriber?s orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall include all required information. Evidence: 1. Resident #2?s physical examination with medication list/ physician?s orders dated 5-25-21 did not include diagnosis for the following: (a) Albuterol, (b) Aspirin, (c) Carvedilol and (d) Crestor. 2. Staff #1 acknowledged during exit on 9-8-21 the aforementioned medications did not have diagnosis on the physician?s order/physical examination medication list.
Plan of Correction:	RCD and RCC will set system to require entry 10/15/2021 of diagnosis for all physicians orders prior to approving order. RCD and RCC are only staff members allowed to approve orders.
Standard #:	22VAC40-73-680-I
Description:	Based on record review and staff interview, the facility failed to ensure the facility?s medication administration record (MAR) included all required information . Evidence: 1. Resident #3?s June 2021 medication administration record (MAR) did not include initials of the direct care staff administering the medication for following: (a) MetFormin, blank four times, (b) Paroxetine, two times and (c) Spironolactone, three times. 2. Staff #1 acknowledged during exit on 9-8-21 the aforementioned blanks on the resident?s MAR.
Plan of Correction:	Med Tech will immediately notify RCD and or ED of missed medications along with explanation of why med was missed. System set to require explanation of missed medication to ensure RCD's and ED's knowledge of missed medication. Responsible party and physician will be informed of missed medication.
Standard #:	22VAC40-73-700-1
Description:	Based on record review and staff interview, the facility failed to ensure when oxygen therapy is provided, all safety precautions shall be met and maintained. Evidence: 1. Resident #4?s narrative/ clinical notes documented resident?s use of oxygen. Resident #6?s individualized service plan (ISP) documented oxygen use. However, resident #4 and #6?s record did not have a valid physician?s or other prescriber?s order that included the following: (s) the oxygen source, (b) the delivery device and (c) the flow rate deemed therapeutic for the resident. 2. Staff #1 acknowledged during the exit on 9-8-21 the aforementioned resident?s record did not have the required oxygen information.
Plan of Correction:	RCD and RCC will obtain physician orders for every resident on 02. Order will be required Ito state full perimeter of usage for each resident. These perimeters will be listed on residents care plans (ISP).
Standard #:	22VAC40-90-40-B
Description:	Based on documents reviewed and staff interview, the facility failed to ensure the criminal history record report shall be obtained on or prior to the 30th day employment for each employee . Evidence: 1. On 7-28-21, the facility did not have documentation of the criminal history record report for fifteen new hires on or prior to the 30th day of employment. The new hire dates ranged from 4-1-21 through 7-12-21. 2. Staff #1 acknowledged on 9-8-21 and 9-16-21, the facility did not obtain on or prior to the 30th day of employment a criminal history record for new employees since the date of hire.
Plan of Correction:	ED has secured an account with the Virginia 11/15/2021 !State Police to run background check for all new hires. IED and BOM will run background checks using new Virginia State Police account for all current employees hired on and after April 1,12021.