VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Friendship Salem Terrace
1851 Harrogate Drive
Salem, VA 24153
(540) 444-0343

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Jan. 23, 2023

Complaint Related: No

Areas Reviewed:

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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

During the on-site exit interview, a discussion occurred with the facility?s administrator and director of nursing to ensure a thorough understanding of UAI completion and on medication management plan components.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 01/23/2023 from 08:30 AM to 05:00 PM 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-220-B
Description:	Based on record review and interviews, the facility failed to ensure that when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in an assisted living facility, all requirements shall be met before direct care or companion services are initiated, including ensuring that private duty personnel are qualified for the types of direct care or companion services they are responsible for providing to residents and to maintain documentation of the qualifications. EVIDENCE: 1. The individualized service plan (ISP) for resident 9, dated 12/13/2022, indicates that the resident receives numerous services that are provided by sitters/caregivers as well as by facility direct care staff to assist her with completing her activities of daily living. 2. An interview with collateral 1 revealed that during their individual shifts collaterals 1, 2, and 3 assist resident 9 with bathing and dressing as well as feeding and evening medication administration. Collateral 1 added that in the evenings, she will go to the medication cart and obtain the medication for resident 9, then bring it back to her room and give it to her. Collateral 1 stated that collaterals 2 and 3 also give resident 9 her medication in the evenings. 3. The signed Private Duty Services form for collateral 2 indicates that collateral 2 will provide the following services: ?Companionship ONLY, no personal care; Transportation to and from meals (by wheelchair or by walking with resident); Transportation to in-house activities or around community (by wheelchair or walking with resident); Assistance in the dining room with opening, cutting, preparation to eat; Assistance with gathering laundry?. 4. The signed Private Duty Services form for collateral 3 indicates that collateral 3 will provide ?Companionship ONLY, no personal care?. 5. The facility?s policy and procedure manual states the following regarding private duty caregivers, ?The PDA and resident/responsible party, and/or agency must provide all necessary documentation prior to the date of services. The PDA can participate in meeting the needs of the resident as identified in the service/care plan and only as appropriate to the PDA?s qualifications and certifications/license(s)?. 6. The facility records for collaterals 1, 2, and 3 do not include verifications that any of the three have received direct care training. In addition, the website for the Virginia Department of Health Professions did not return any results to verify that there were any direct care credentials for collaterals 2 and 3.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on record review and interviews, the facility failed to ensure that when private duty personnel who are not employees of a licensed home care organization provide direct care or companion services to residents in an assisted living facility, all requirements shall be met before direct care or companion services are initiated, including ensuring that private duty personnel are qualified for the types of direct care or companion services they are responsible for providing to residents and to maintain documentation of the qualifications. A 100% audit of all resident records working with a Private Duty Agent will be completed and all required documentation added to our residents? administrative files. All direct care staff will be in-serviced to this standard and ensure proper communication with the management office when identifying the resident?s request to hire Private Duty Agents (PDAs) in the facility. All new Private Duty Agents will be onboarded with our Human Resources Dept. at time of hire to ensure all documentation is completed and certification and licensure are up to date on the VDHP site.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to ensure individualized service plans (ISPs) contained all identified needs. EVIDENCE: 1. The most recent fall risk in the record for resident 3, dated 07/07/2022, indicated that the resident is a high fall risk; however, the ISP for the resident, dated 10/18/2022, does not include documentation that the resident is a high fall risk. 2. The most recent fall risk in the record for resident 7, dated 11/12/2022, indicated that the resident is a high fall risk; however, the ISP for the resident, revised on 11/14/2022, does not include documentation that the resident is a high fall risk. 3. The uniform assessment instrument (UAI) for resident 4, dated 09/12/2022, indicated that the resident is disoriented to all spheres all the time and will answer to her name but that is all; however, the aforementioned information is not included on the resident?s ISP with a revision date of 01/13/2023.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on resident record review, the facility failed to ensure individualized service plans (ISPs) contained all identified needs. 100% Audit of ISPs along with the Fall Risk Assessments will be completed to ensure all items noted will be indicated on both documents.
Standard #:	22VAC40-73-680-A
Description:	Based on record review and interview, the facility failed to ensure that only staff who are licensed, registered, or acting as medication aides on a provisional basis shall administer drugs to those residents who are dependent on medication administration as documented on the UAI. EVIDENCE: 1. The UAI for resident 9, dated 11/03/2022, indicates that the resident requires medication to be administered by an RMA/LPN. 2. An interview with collateral 1 revealed that collaterals 1, 2, and 3 give resident 9 her medication in the evenings. 3. The facility records for collaterals 1, 2, and 3 do not include any verifications they are licensed or registered to give medications in Virginia or acting as provisional a medication aide. The website for the Virginia Department of Health Professions did not return any results to verify any Virginia medication administration credentials for collaterals 1, 2, and 3.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on record review and interview, the facility failed to ensure that only staff who are licensed, registered, or acting as medication aides on a provisional basis shall administer drugs to those residents who are dependent on medication administration as documented on the UAI. All current PDAs & new hires will be trained to ALF regulatory standards in relation to medication administration and will also be onboarded with our Human Resources Dept. at time of hire to ensure all documentation is completed and certification and licensure are up to date on the VDHP site.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. EVIDENCE: 1. On the date of inspection, the January 2023 MAR for resident 6 contained the following medication order, dated 01/13/2023: ?Zoloft Oral Tablet 100 MG (Sertraline HCl) Give 1 tablet by mouth one time a day for Depression?. 2. Alternately, the record for resident 6 contained signed physician?s orders on 01/13/2023 stating ?Increase Zoloft to 150mg daily x 3 days then increase to 200mg daily ? depression?. 3. Interview with staff 3 indicated that she was not aware of the increase of the Zoloft to 200 MG.
Plan of Correction:	This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by the Virginia Department of Social Services. Based on record review and interview, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber?s instructions. All other residents may have been potentially affected. The DON and ADON will conduct a 100% audit of all resident?s physician orders and MAR?s over the past 30 days to identify resident at risk. Residents identified at risk will be corrected at time of discovery and their individualized service plans updated to reflect their resident specific needs. The attending physicians will be notified of each negative finding and a facility Incident & Accident Form will be completed for each negative finding.