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: Yes

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS X 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8-11-2022, 8:51 a.m. ? 10:30 a.m. The Acknowledgement of Inspection form was emailed to the provider for the date of the inspection. A complaint was received by VDSS Division of Licensing on July 18, 2022 regarding allegations in the areas of Administration and Administrative Services, Resident Care and Related Services, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were Administration and Administrative Services and Resident Care and Related Services. A violation notice was issued; any violation(s) not related to the complaint 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 #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on record review and interview with staff, the facility failed to ensure compliance with the facility's own policies and procedures. Evidence: 1. The facility?s ?Fall Management Program? effective 06-2022 documented, ?If the assessment in Vitals has a notation under the fall section, interventions are to be established and documented on the Service Plan? and ?Update the care plan/service plan with new interventions appropriate for the resident?s cognitive level and relative to the conditions involving the fall? A new intervention must be developed for each fall, or a determination made those current interventions are appropriate?? 2. Resident #1 admitted 12-27-2021. Resident #1?s Progress Notes documented two falls, on 5-22-2022 and 7-11-2022. Resident #1?s Fall Risk Assessment interventions for 5-22-2022 documented, ?Medium risk. Keep resident in common area during waking hours? and under 7-11-2022 documented, ?high risk ? continue to monitor?. 3. Resident #1?s current ISP dated 3-9-2022 identified the resident as Fall Risk with interventions dated 1-02-2022 and read under services, ?The resident is at risk for falls due to a history of falls and poor safety awareness. Fall reduction policy will be followed. Any changes will be reported to the DHW.? No updates were documented for the falls. 4. Resident #2 admitted 1-16-2020. Resident #2?s Progress Notes documented two falls, on 5-31-2022 and 8-05-2022. Resident #2?s Fall Risk Assessment interventions for 5-31-2022 documented, ?continue to monitor? and under 8-05-2022, ?high risk ? communicate needs to staff.? 5. Resident #2?s current ISP dated 3-22-2022 did not identify Fall Risk nor the interventions as a service need. No updates were documented for the falls. 6. Resident #3 admitted 2-03-2022. Resident #3?s Progress Notes documented falls on 4-25-2022, 6-20-2022, 6-28-2022, 7-14-2022 (twice), 7-18-2022, and 8-10-2022. 7. Resident #3?s current ISP dated 2-15-2022 identified the resident as a High Fall Risk on 4-22-2022 and read, ?Company fall reduction plan will be followed. Community will ensure resident is safe while ambulating.? No updates were documented for the falls. Resident #3?s Fall Risk Assessments for the following dates identified the following interventions: a. 4-25-2022: high risk ? eval for assistive device? b. 5-16-2022: high risk. Continue monitoring. PT eval? c. 6-18-2022: high risk. Encourage use of walker. d. 6-20-2022: high risk ? PT services? e. 6-28-2022: high risk ? continue to monitor f. 7-06-2022: hospice?? g. 7-14-2022: consider hospice services h. 7-18-2022: high risk. Family considering hospice. i. 8-10-2022: continue fall precautions. 8. Resident #4 admitted 12-01-2021. Resident #4?s Progress Notes documented falls on 12-04-2021, 5-07-2022, 5-09-2022, 5-15-2022, 5-16-2022, 5-19-2022, 5-27-2022, and 8-01-2022. 9. Resident #4?s current ISP dated 11-30-2021 identified the resident as a fall risk, and the service documented, ?company fall reduction policy to be followed.? No updates were documented for the falls. Resident #4?s Fall Risk Assessments for the following dates identified the following interventions: a. 12-04-2021 (x2): Fall #1 and Fall #2 ? score communicated to team members b. 2-03-2022: high fall risk - status communicated to staff c. 5-07-2022: high risk, continue to monitor. PT/OT services? d. 5-09-2022: same as above e. 5-15-2022: high risk ? PT/OT services requested f. 5-16-2022: high risk ? PT/OT services requested g. 5-27-2022: high risk. continue to monitor h. 7-20-2022: high risk. Continue to monitor i. 8-01-2022: high risk. Continue to monitor 10. The facility?s policy for ?Falls Management Program? was not followed regarding Resident #1, Resident #2, Resident #3, and Resident #4?s falls.
Plan of Correction:	Going forward, the facility will document all fall-interventions on both the fall-risk assessment and the Individualized Service Plan (ISP) to ensure that the facility?s Fall Management Program policy is adhered to.
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record review and interview with staff, the facility failed to ensure the comprehensive individualized service plan (ISP) completed within 30 days after admission. Evidence: 1. Resident #4 admitted 12-01-2021. Resident #4?s record contained a preliminary ISP dated 11-30-2021 was the only ISP in the record. 2. Staff #1 confirmed the ISP dated 11-30-2021 was the preliminary ISP and that a comprehensive ISP had not been completed for Resident #4.
Plan of Correction:	Going forward, the facility will ensure the comprehensive individualized service plan (ISP) is completed within 30 days after admission.