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 29, 2021 , Aug. 4, 2021 and Sept. 9, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated complaint inspection was initiated on 7-27-21 and concluded on 9-9-21. A complaint was received by the department regarding allegations in the areas of resident care and related services. The resident services director was contacted by telephone to conduct the investigation. The licensing inspector emailed the resident services director and administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 7-29-21. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the (complaint(s)/self-report) but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-310-H
Complaint related:	No
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 #1?s record did not have a treatment plan for Haloperidol and Lorazepam medications documented on resident?s unsigned and undated physician?s orders printed at 11:24 a.m. 2. Staff #1 acknowledged on 9-8-21 during exit meeting, treatment plans were available for resident #1.
Plan of Correction:	ED, RDS will audit orders to ensure there are treatments plans and all orders are signed by physician.
Standard #:	22VAC40-73-440-D
Complaint related:	No
Description:	Based on record review and staff interview, for private pay individuals, the facility failed to ensure that the uniform assessment instrument (UAI) is completed as required by 22VAC30-110. Evidence: 1. Resident #1?s uniformed assessment instrument dated 4-8-20, was completed by a designated facility staff, however, it was not signed by the administrator as required. 2. Staff #1 acknowledged during the exit on 9-8-21, the aforementioned resident?s UAI was not completed as required.
Plan of Correction:	ED, RSD and RCC will audit all resident's charts to ensue that ll ISPs and UAI are up to date and fully executed.
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on record review, the facility failed to ensure an annual reassessment and reassessment due to significant change in the resident?s condition, using the UAI, shall be 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: 1. Resident #1?s uniform assessment instrument (UAI) was lasted completed, signed and dated on 4-8-20. 2. Staff #1 acknowledged during the exit on 9-8-21, the aforementioned resident?s UAI was not updated since 4-8-20.
Plan of Correction:	ED, RSD and RCC will audit all residents charts to ensure that all ISPs and UAI are up to date. We will also update system to notify us prior to next due date.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on record review and staff interview, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs. Evidence: 1. Resident #1?s ISP documented resident is disoriented some spheres, all the time, however, the ISP documented the following intervention/ services to be provided: ?Changes in orientation will be reported to MD as needed thru next review?. a. Resident`s ISP document resident?s incontinent needs for bowel and bladder, however, the ISP did not document the use of incontinent products. Interview with collateral staff during on-site visit, staff stated resident use?s incontinent products. The inspectors also observed incontinent products in resident?s room. b. Bathing need is documented as mechanical help/ human help/ physical assistance, however, the intervention is documented as, ?Report any changes in condition to physician and follow any orders?. 2. Staff #1 acknowledged during the exit on 9-8-21, the aforementioned identified needs? intervention/ what staff will do was not addressed on the ISP for resident #1.
Plan of Correction:	RSD and RCC will review all ISPs and UAI to ensure that they clearly indicate the resident's needs in all areas including ADL. ED will review and request any additional information needed to ensure complete picture of residents needs is noted on their ISP.
Standard #:	22VAC40-73-450-D
Complaint related:	No
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. Resident #1?s record document resident is receiving hospice services, however, the resident?s ISP provided 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 resident?s ISP did not document the hospice services.
Plan of Correction:	RSD will communicate with hospice services for resident to ensure that they are providing their full treatment plan of the resident. This information will be documented on ISP and updated as condition changes occur.
Standard #:	22VAC40-73-700-1
Complaint related:	No
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 #1?s individualized service plan documented resident?s use of oxygen. However, the 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:	RSD will make sure that there is a signed physicians order for all residents on oxygen, and ensure that ISP lists all pertinent information such as delivery and flow rate.