VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Discovery Village at the West End
2422 University Park Boulevard
Richmond, VA 23233
(804) 554-1555

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Aug. 11, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES X 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS X 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

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: 8-11-2022, 10:31 ? 11:15 a.m. The Acknowledgement of Inspection form was emailed and sent to the facility for the date of the inspection. A self-reported incident was received by VDSS Division of Licensing on July 22, 2022 regarding allegations in the area of: Resident Care and Related Services. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 #:	22VAC40-73-220-A
Description:	Based on record review and interview with staff, the facility failed to ensure when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the following applies: Before direct care or companion services are initiated, the facility shall obtain, in writing, information on the type and frequency of the services to be delivered to the resident by private duty personnel, review the information to determine if it is acceptable, and provide notification to the home care organization regarding any needed changes. The direct care or companion services provided by private duty personnel to meet identified needs shall be reflected on the resident's individualized service plan. The facility shall ensure that the requirements of 22VAC40-73-250 D 1 through D 4 regarding tuberculosis are applied to private duty personnel and that the required reports are maintained by the facility or the licensed home care organization. The facility shall provide orientation and training to private duty personnel regarding the facility's policies and procedures related to the duties of private duty personnel. The facility shall ensure that documentation of resident care required by this chapter is maintained. Evidence: 1. Per email with Staff #2 on 7-26-2022, sitters for Resident #1 were implemented from 8:00 p.m. to 7:00 a.m. due to a wandering incident that occurred on 7-22-2022. 2. Upon review of Resident #1?s record on 8-11-2022, there no documentation to include no information on the services that Resident #1 was receiving by the private duty personnel (sitters), nor was it reflected on Resident #1?s individualized service plan. Additionally, Staff #1 confirmed the private duty personnel for Resident #1 did not receive orientation and training regarding the facility's policies and procedures related to the duties of private duty personnel. 3. Staff #1 confirmed there was no paperwork for this resident?s private duty care in the record, nor was the resident?s ISP updated with the identified needs. Per email with Staff #1 on 8-11-2022, ?[Resident #1] had private-duty sitters through [Agency Name] Saturday, 7/23 through Wednesday, 7/27.?
Plan of Correction:	Going forward the facility shall obtain, in writing, all requirements related to standard # 220A and include the information in the resident?s care plan. Additionally, a TB screening and orientation will be conducted for all private-duty personnel and documentation of such will be kept in the resident?s file.
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview with staff, the facility failed to ensure the uniform assessment instrument (UAI) was completed whenever there is a significant change in the resident's condition. Evidence: 1. Resident #1 admitted 2-16-2022. Resident #1?s current UAI dated 3-08-2022 does not have behaviors listed for ?aggressive/disruptive? or ?wandering?; however, the following Nurse?s Notes document these behaviors: a. 5-20-2022 ? ?? Resident [#1] making rude comments to the employees? resident stating ?why don?t you do something important and get me a drink?? b. 5-20-2022 ? ?? confused some days and refuses meds?? c. 6-15-2022 ? ?? observed on the security cameras going into the IT closet? unplugged power cords?? d. 6-30-2022 ? ?? found walking near the stoplight at [Street names] ?? e. 6-30-2022 ? ?? arrived back at facility @0445 he was a bit frustrated ? staff talked with resident he calmed down?? f. 7-21-2022 ? ?Resident [#1] agitated and threatens to set the trash dumpsters and facility on fire to get attention from the managers?. Also closed himself in game room and blocked the doors with furniture for almost an hour?? g. 7-22-22 ? ?Resident [#1] was unable to be located?found near the facility by police/EMT providers?? 2. Staff #1 acknowledged Resident #1?s current UAI was not updated to reflect a change in condition from admission.
Plan of Correction:	Going forward, the facility will ensure that the Uniform Assessment Instrument (UAI) is updated in a timely manner whenever there is a significant change in the resident?s condition.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview with staff, the facility failed to ensure individualized service plans (ISPs) were updated as needed for a significant change of a resident?s condition. Evidence: 1. Resident #1 admitted 2-16-2022. Between May and July 2022, Resident #1 had six documented incidents of behaviors per the resident?s Nurse?s Notes: three wandering, and four incidents of aggressive/disruptive behaviors. 2. Resident #1?s current ISP dated 3-08-2022 did not document wandering or aggressive/disruptive behaviors.
Plan of Correction:	Going forward, the facility will ensure that the Individualized Service Plan (ISP) is updated in a timely manner whenever there is a significant change in the resident?s condition.
Standard #:	22VAC40-73-460-D
Description:	Based on record review and interview with staff, the facility failed to ensure supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: 1. A self-reported incident was received by Staff #2 via email on 7-22-2022 at 5:00 p.m. that documented, ?Resident [#1] who lives in assisted living was unable to be located at 10 am rounds. After looking for [Resident #1] for 20 minutes 911 was called to help assist with finding resident due to concerns of the hot weather today. Resident [#1] eventually returned to the facility on [Resident #1?s] own. Noted with pants and shoes on but without a shirt?? 2. Resident #1?s Nurse?s Notes documented the following on 7-22-2022 at 3:00 p.m., ?Resident [#1] was unable to be located at 10a, round to be given medication. After 20 minute search unable to locate. 911 was called search was implemented. Resident [#1] was found back near the facility by police/EMT providers. Had been in the woods for this time. Noted with shrubs and dirt on his body, had no shirt on and was extremely overheated. EMTs said resident was stable and refused to take him to the ER due to being medically stable and alert to person, place, time? [Doctors? names] involved and advised to take to ER for medical and psych eval in hopes of psychiatric evaluation?? 3. According to the National Weather Service (weather.gov), the high temperature on 7-22-2022 was 94 degrees Fahrenheit. Per Staff #2, the resident was last seen by staff at around 9:30 a.m. and did not return until around noon, with 2.5 hours unaccounted for. 4. Resident #1 had a history of wandering behaviors as Staff #2 acknowledged in email on 7-26-2022, ?Resident [#1] does have a diagnosis of dementia? Resident [#1] has had some episodes of wandering behaviors before?? Nurse?s Note on 6-15-2022 documented, ?Resident [#1] observed on the security cameras going into the IT closet at approximately 9pm on 6/14. Resident [#1] unplugged wifi and security camera power cords?? Nurse?s Note on 6-30-2022 at 2:00 p.m. documented, ?Facility notified that [resident #1] was found walking near the stoplight at [Street names] by a maintenance employee at [other facility name]. Resident [#1] stated that he was looking for a church. Staff of discovery village went to pick up [Resident #1] by car??Resident #1 was seen in the hospital on 6-20-2022 per hospital discharge summary for ?adjustment reaction.?
Plan of Correction:	The community will provide attention to specialized needs, such as wandering from the premises, by documenting the specialized needs in the resident?s care plan, along with a course of action to ensure specialized needs are monitored closely by all staff members in the community. The care plan will include a plan-of-action to ensure specialized needs are identified and addressed.