VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Petersburg Home for Ladies
311 South Jefferson Street
Petersburg, VA 23803
(804) 861-0660

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: May 3, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73 BUILDINGS AND GROUND ? 22VAC40-73 EMERGENCY PREPAREDNESS ? 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ? ARTICLE 1 ? SUBJECTIVITY ? 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS ? 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 ? 22VAC40-80 THE LICENSE ? 22VAC40-80 THE LICENSING PROCESS ? 22VAC40-80 COMPLAINT INVESTIGATION ? 22VAC40-80 SANCTIONS

Technical Assistance:

Hospice service plans addressed in ISP Healthcare oversight specifications Corresponding of UAI and ISP dates Administrator or designee approval for SCU placement

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5-03-2022, 9:22 a.m. to 2:00 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on record review, the facility failed to ensure prior to placing a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia in a safe, secure environment (SSE), the facility shall document that the order of priority specified in subsection A of this section was followed, and the documentation shall be retained in the resident's file. Evidence: 1. Resident #1 admitted 12-01-2017 to the facility, and approval for SSE placement by the physician was dated 9-28-2021. Resident #1?s ?Approval for Placement in Special Care Unit? dated 9-28-2021 was blank for the question: ?Explanation of why written approval was not obtained from each individual higher on the list of priority.? 2. Resident #2 admitted 2-24-2022 to the facility?s SSE. Resident #2?s ?Approval for Placement in Special Care Unit? dated 1-28-2022 was blank for the question: ?Explanation of why written approval was not obtained from each individual higher on the list of priority.?
Plan of Correction:	New Approval for Placement in Special Care Unit completed for Resident #1 and resident #2 with "Explanation of why written approval was not obtained from each individual higher on the list of priority" completed. All residents residing in SSE approval for placement audited for completeness and justification, new approvals completed as needed. All new admissions into a special care unit chart will be audited prior to admission for completeness of Approval for Placement form. DON education on regulation regarding SSE (pages 135-138 of regulation manual)
Standard #:	22VAC40-73-450-A
Description:	Based on record review and interview with staff, the facility failed to ensure on or within seven days prior to the day of admission, a preliminary plan of care [ISP] shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. The preliminary plan shall be identified as such. Evidence: 1. The following residents? preliminary plan of care were identified as the ?preliminary? by Staff #1 and did not address basic needs of the residents: a. Resident #2 admitted 2-24-2022. Resident #2?s preliminary ISP was dated 3-08-2022 and did not document that resident is in a safe secure environment as of date of admission. Resident #2?s plan also did not address needs for wheeling assistance or behavior pattern; however, the resident?s UAI dated 1-20-2022 documented wheeling assistance (performed by others) and behavior pattern (wandering/passive ? weekly or more); b. Resident #4 admitted 8-02-2021. Resident #4?s preliminary ISP was dated 8-13-2021 and did not document that resident requires assistance with dressing, toileting, or bladder assistance; however, the resident?s UAI dated 7-20-2021 documented dressing and toileting assistance (human help, physical assistance) and bladder incontinence (less than weekly); c. Resident #5 admitted 3-14-2022. Resident #5?s preliminary ISP was dated 4-12-2022, and did not document that resident requires assistance with eating/feeding, bowel and bladder incontinence, meal preparation, housekeeping, money management, and disorientation; however the resident?s UAI dated 3-08-2022 documented eating/feeding assistance (human help physical assistance), bowel incontinence (less than weekly), bladder incontinence (weekly or more), and assistance with meal preparation, housekeeping, laundry, and money management. Additionally, Resident #5?s UAI documented, ?Disoriented ? some spheres, some of the time. Spheres affected: place, time?; however, this was not documented on the ISP. d. Resident #6 admitted 3-29-2022. Resident #6?s preliminary ISP was dated 4-29-2022 and did not document toileting, transferring, bladder continence, walking, wheeling, mobility, meal preparation, housekeeping, laundry, money management, and orientation; however, Resident #6?s UAI dated 3-04-2022 documented the following: toileting (human help, supervision), transferring, (human help, supervision), bladder incontinence, (weekly or more), wheeling (mechanical and human help physical assistance), mobility (mechanical and human help supervision), and requires assistance with meal preparation, housekeeping, laundry, money management. Additionally, Resident #6?s UAI documented orientation ?Disoriented ? some spheres, some of the time, spheres affected: time?; however, this was not documented on the ISP. 2. Staff #1 confirmed in interview the aforementioned resident ISPs were preliminary and were not identified as such, and stated ??[Staff #6] was unaware, she thought it was 30 days?? regarding the residents? plan of cares not being developed timely. Additionally, the needs identified were not included on the preliminary plan of care for the above mentioned residents.
Plan of Correction:	Resident #2, #4, #5, and #6 ISP reviewed and revised to reflect current needs. All new admissions from the last 30 days will be audited for accuracy and reflection of UAI. All ISP's to be labeled as preliminary or comprehensive moving forward. DON education on ISP regulations (pages 66-70 in regulation manual) All new admissions to have preliminary ISP completed reflecting preadmission assessment dated day of admission up to 7 days prior. These ISP will be identified as preliminary. New admission ISP's will be audited on day of admission and weekly until comprehensive ISP is completed for 4 weeks.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) included a description of identified needs and date identified based upon the UAI and other sources. Evidence: 1. Resident #1 admitted 12-01-2017. Resident #1?s most current ISP dated 3-15-2022 did not identify bladder incontinence as a need on the ISP; however, Resident #1?s UAI dated 12-10-2021 documented under bladder continence, ?Incontinent weekly or more?. Additionally, Resident #1?s ISP didn?t address orientation; however, Resident #1?s UAI documented Resident #1 is ?Disoriented ? Some spheres, some of the time; spheres affected: time?. 2. Resident #3 admitted 10-25-2021. Resident #3?s most current ISP dated 4-28-2022 did not identify assistance with meal preparation, housekeeping, laundry, or bladder incontinence; however, Resident #3?s UAI dated 10-21-2021 documented, ?Yes? for assistance with meal preparation, housekeeping, and laundry, as well as ?Incontinent weekly or more? under bladder continence. 3. Resident #7 admitted 3-05-2018. Resident #7?s most current ISP dated 3-22-2022 did not document assistance with bladder continence, meal preparation, housekeeping, laundry and money management. Resident #7?s UAI dated 3-22-2022 documented bladder continence, ?incontinent less than weekly?, and ?Yes? to assistance with meal preparation, housekeeping, laundry and money management. 4. Resident #8 admitted 3-7-2022. Resident #8?s most current ISP dated 4-24-2022 did not document assistance with transfers, meal preparation, housekeeping, laundry and money management. Resident #8?s UAI dated 3-01-2022 documented, ?human help, supervision? for transferring, and ?Yes? to assistance with meal preparation, housekeeping, laundry and money management.
Plan of Correction:	Resident #1, #3, #7, and #8 ISP reviewed and revised to reflect current needs. 100% audit of current ISP's for all current residents to be conducted to check for accuracy compared to most recent UAI as well as accurate to reflect residents current needs and dates identified. ISP's to be audited weekly for any changes and reflection of current needs for 4 weeks. After 4 weeks ISP's will be reviewed for accuracy every 6 months and annually. DON educated on ISP regulations (pages 66-70 in regulation manual)
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure the individualized service plan (ISP) was signed and by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. These requirements shall also apply to reviews and updates of the plan. Evidence: 1. Resident #4 admitted 8-02-2021. Resident #4?s ISP contained updates as of 12-10-2021 for services including ?hospice? and ?DNR?; however, no signatures were documented for the update by facility staff or the resident/legal representative.
Plan of Correction:	Resident #4 ISP signed by DON and residents' legal representative with recent updates. 100% audit of current ISP's for all current residents to be conducted to check for updates reflected on the ISP and signature of DON and resident/legal representative. DON educated on ISP regulations (pages 66-70 in regulation manual)
Standard #:	22VAC40-73-860-G
Description:	Based on observation and interview with staff, the facility failed to ensure hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. Evidence: 1. The following rooms had hot water above the range of 105?F to 120?F: A. 130.7?F ? Room 3 B. 130.3?F ? Room 16 C. 120.7?F ? Room 55 D. 130.3?F ? South shower room E. 129.1?F ? Room 37 2. Staff #1 as present during the tour and acknowledged the aforementioned temperatures were above the required range for hot water at taps.
Plan of Correction:	Water temperatures in room 3, 16, 55, 37 and South shower room rechecked and temperatures within appropriate range. Daily water temperatures to be taken in 1 resident's and 1 bathroom on each hallway for 4 weeks. Temperatures will continue to be monitored monthly and as needed after 4 weeks for 6 months. Assistant Administrator and Maintenance team education on general requirements regulation (page 115 in regulation manual).
Standard #:	22VAC40-90-30-B
Description:	Based on record review, the facility failed to ensure the sworn statement or affirmation was completed for all applicants for employment. Evidence: 1. The following staff did not have a completed sworn statement or affirmation in their records: A. Staff #2: Date of hire 2-13-2022, no sworn statement, B. Staff #4: Date of hire 9-06-2021, sworn statement not complete (no answers checked); and C. Staff #5: Date of hire 2-28-2022, no sworn statement. 2. Staff #1 acknowledged the sworn statements for the aforementioned staff weren?t present.
Plan of Correction:	100% audit of current employee records completed to ensure all current employees have a sworn statement or affirmation in their records. All completed sworn statements or affirmations checked for completeness and accuracy. All new employees will be audited prior to hire for completed sworn statements. Business office and Administrator educated on regulations for background checks and sworn statement of affirmation, pages 1-6 reviewed)
Standard #:	63.2-1720-C-2
Description:	Section 63.2-1720 of the Code of Virginia requires all employees of assisted living facilities and adult day care centers, as defined by ?63.2-100 of the Code of Virginia, requires all employees of assisted living facilities and adult day care centers, as defined by ? 63.2-100 of the Code of Virginia, to obtain a criminal history record report from the Department of State Police. Evidence: 1. Staff #5 (hired 2-28-2022) did not have a criminal history record report from the Department of State Police in their records and instead a national criminal record search.
Plan of Correction:	Staff #5 Department of State Police criminal history record report completed and updated in employee's record. 100% audit of current employee records completed to ensure all current employee have a Department of State Police criminal history record in their employee record. All new employees will be audited prior to hire for completed sworn statements. Business office and Administrator educated on regulations for background checks, (pages 1-6 reviewed)