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 16, 2022 and March 17, 2022

Complaint Related: No

Comments:

An unannounced monitoring inspection was Initiated at the facility on 03/16/2022 and concluded on 03/17/2022. The Inspector conducted the entrance interview with the facility Administrator. The facility offered eighty-nine residents in care to include the residents In the facility's safe and secure environment. The Inspector reviewed along with the facility Administrator five resident records, five staff records, facility policies and procedures as well as current Standards for Licensed Assisted Living Facilities. A walk through of the physical plant conducted on both days revealed no obvious concerns. The onsite inspection conducted at the facility on 03/16/2022 was conducted between the approximate time of 9:30a.m and concluded at approximately 1 :30p.m. The onslte Inspection conducted at the facility on 03/17/2022 was conducted between the approximate time of 9:52a.m and concluded at approximately 4:12p.m. 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. An exit interview was conducted where findings of 03/16, 17 /2022 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. Please contact me at Angela.r.reaves@dss.virginia.gov or (804) 840-0253 if you have any questions.

Violations:

Standard #:	22VAC40-73-430-H-1
Description:	Based on the review of facility records and staff interviews conducted the facility failed ensure that at the time of discharge, the assisted living facility provided to the resident and, as appro- priate, his legal representative and designated contact person a dated statement signed by the licensee or administrator that contains all of the required information. Evidence: Resident #s 6, 7 and 8 During interviews the facility Administrator reported that resident #s 6, 7 and 8 were deceased but did not submit upon request doc- umentation of the date of discharge from the facilrty. The facility's discharge document for these three residents that was submitted for the inspector's review only notes the residents names and has no other information documented.
Plan of Correction:	Discharge statements have been completed for the 3 reported that discharge statements were incomplete. All discharged records will be audited to ensure discharge statements are being completed timely, with all required information, and appropriate signatures. All discharges will have discharge statement sent to legal representative and/or designated contact person as appropriate. Educate licensed staff on process. Responsible persons for implementing and monitoring for continued compliance Unit Coordinators, DON and ED."
Standard #:	22VAC40-73-450-C
Description:	Based on the review of facility records and staff interviews conducted the facility failed ensure that a resident comprehensive individualized service plan is completed within 30 days after admission. Evidence: Resident #3-Documented date of admission 08/14/2021 The ISP that was submitted for the inspector's review is dated 08/16/2021 two days after admission. Upon request the facility did not submit for the Inspector's review documenta- tion that a comprehensive ISP had been devel- oped for resident #3.
Plan of Correction:	FACILITY RESPONSE "Comprehensive ISP to be completed on all new residents within 30 days of move in. Audit all new resident charts to ensure comprehensive ISP completed within specified time and signed by all required parties. Educate licensed staff on process. Monitor quarterly to ensure compliance. Responsible persons for implementing and monitoring for continued compliance Unit Coordinators, DON and ED."
Standard #:	22VAC40-73-450-E
Description:	Based on the review of facility records and staff interviews conducted the facility failed ensure that resident individualized service individual- ized service plan is signed and dated by the licensee, administrator, or his deslgnee, (i.e., the person who has developed the plan), and by the resident or his legal representative. The plan shall also indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person who was Involved in the development of the plan shall be included. These requirements shall hall also apply to reviews and updates of the plan. Evidence: Resident# 1-Documented date of admission 05/22/2019 The resident's Individualized Service Plan document that was submitted for the inspector's review that notes a needs identification date of 2/17 /22 is not signed and dated by the licensee, administrator, or his designee, (Le., the person who has developed the plan), and by the resident or his legal representative. The ISP document also does not indicate any other individuals who contributed to the development of the plan. Resident #2-Documented date of admission 08/10/2018 The resident's ISP dated 06/25/2021, is not signed by the resident or his legal representative. Resident #4- Documented date of admission 08/17/2020 The resident's Individualized Service Plan document that was submitted for the inspectors review that notes a needs identification date of 09/24/2021 is not signed or dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. The ISP document also does not indicate any other individuals who contributed to the development of the plan.
Plan of Correction:	FACILITY RESPONSE " All ISPs will be reviewed and updated as necessary. Setting up ISP meetings with Residents and legal representatives, to review and sign ISP. Educate all Licensed staff on process. Monitor for compliance monthly with audit tool created to ensure ISPs are updated with new orders, interventions and services received. Ensure all ISP?s have all required signatures, to include Resident and /or Family representative, person or persons updating ISP and Administrator/ Licensee or designee. Responsible person for implementing and monitoring for continued compliance Unit Coordinators, DON and ED. "
Standard #:	22VAC40-73-450-F
Description:	Based on interviews conducted with facility staff and the review of facility records, the facility failed to ensure that resident Individualized ser- vice plans (ISP) was reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. Evidence: Resident #1-Documented date of admission 05/22/2019 Facility records that was submitted for the inspector's review notes that the resident's occupational therapy services began January 2022 to the present and speech therapy was initiated on 03/01/2022. The resident's ISP that notes a needs identifica- tlon date of 2/17 /22 is not updated to note that the resident Is receiving occupational and speech therapy. Resident #3-Documented date of admission 08/14/2021 The resident's 08/17/2021 ISP that was submit? ted for the inspectors review on 03/16-17/2022 does not note that therapy for the resident was initiated 03/07/2022. Resident #5- The facility's Nutrition Consultation document dated 1/18/2022 for resident #5 that was sub- mitted for the inspector's review notes under the heading Problem "wt/loss?. The resident's ISP dated 03/24/2021 and 02/22/2022 is not updated to note that dietary intervention(s) have been Implemented to address the resident's unplanned weight loss.
Plan of Correction:	FACILITY RESPONSE "Resident charts reviewed at time of survey, those receiving therapy services, seen by RD, pharmacy, and/ or MD, any recommendations or new orders will be updated to resident?s ISP. ISP meetings being set up with families/residents to obtain necessary signatures. Audit all resident?s ISP that receives therapy service, seen by RD and / or pharmacy to ensure ISP shows services received, recommendations and new orders. Educate all Licensed staff on process. Monitor for compliance quarterly with audit tool created to ensure ISPs are updated with new orders, interventions and services received. Ensure all ISP?s have all required signatures, to include Resident and /or Family representative, person or persons updating ISP and Administrator/ Licensee or designee. Responsible persons for implementing and monitoring for continued compliance Unit Coordinators, DON and ED.
Standard #:	22VAC40-73-580-F
Description:	Based on Interviews conducted with facility staff and the review of facility records, the facility failed to ensure that the facility Implement Interventions as soon as a nutritional problem is suspected and that notification was made to the attending physician If a significant weight loss Is identified In any resident who is not on a physician-approved weight reduction program. Evidence: Resident #5- The facility's Nutrition Consultation document dated 1/18/2022 for resident #5 that was sub- mitted for the inspector's review notes under the heading Problem "wt/loss?. Upon request the facility did not submit for the inspector's review documentation that the residents' physician had been made aware of the resident's weight loss.
Plan of Correction:	FACILITY'S RESPONSE "Current enhanced diet plan is in place. Resident?s weight is stable, and physician has been notified of their current weights and changes. Audit all nutrition consultation documentation for any current residents to ensure all recommendations have been sent to attending physician and physician orders implemented. All resident weights will be taken monthly and will be monitored monthly for any significant change. Any resident experiencing a significant change in weight will have this change documented, their RP notified, and their physician notified. Physician orders regarding diet plan will be implemented and documented. Educate all Licensed staff on process. All resident weights will be monitored for compliance monthly with audit tool. Responsible persons for implementing and monitoring for continued compliance Unit Coordinators, DON and ED."