VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Lady of Perpetual Help Health Center
4560 Princess Anne Road
Va beach, VA 23462
(757) 495-4211

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: March 28, 2023 and March 30, 2023

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 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Technical Assistance:

22VAC40-73-290

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: 03/28/2023 from 8:30 am to 4:45 pm and 03/30/2023 from 8:25 am to 11:15 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 5 An exit meeting will be conducted to review the inspection findings. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-210-G
Description:	Based on record review, the facility failed to ensure there is documentation of the type of training received, the entity that provided the training, number of hours of training, and dates of the training kept by the facility in a manner that allows for identification by individual staff person and is considered part of the staff member's record. Evidence: 1. The records for Staff #3 and Staff #5 do not include documentation of the annual refresher course in medication administration for medication aides.
Plan of Correction:	1) Staff #5 is scheduled to take the annual refresher course on 4/13/2023. Staff #3 is no longer serving in a Registered Medication Aide capacity. 2) An audit of the Registered Medication Aide?s files will be performed to assess for the completion of the annual refresher course in medication administration for medication aides. Those not in compliance will be scheduled for the next available class. 3) Community educator will complete the training course, to be able to offer the refresher course, in-house, to our employees. 4) The Director of Resident Services will review the Registered Medication Aide list, monthly, to determine who is due for their annual refresher course and have them scheduled, accordingly.
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to annually complete a risk assessment for tuberculosis on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. The last risk assessment for TB completed for Resident #6 and Resident #7 was 3/11/2022.
Plan of Correction:	1) The risk assessment for TB was completed for residents #6 and #7, on 3/28/2023 2) An audit will be performed, by the Unit Coordinators to ensure each resident has an annual TB assessment completed. 3) The Unit Coordinator will perform a quarterly audit of the risk assessments for TB to ensure compliance is achieved. Audits will occur quarterly, for the next 3 quarters. 4) The Director of Resident Services will review the quarterly audits and submit to the QA committee, for their review.
Standard #:	22VAC40-73-325-A
Description:	Based on record review, the facility failed to ensure for residents who meet the criteria for assisted living care, by the time the comprehensive ISP is completed, a written fall risk rating be completed. Evidence: 1. Upon review of the resident?s record, Resident #2 meets the criteria for assisted living care; however, there is no documentation of a fall risk rating being completed in the resident?s record.
Plan of Correction:	1) The fall risk assessment for resident #2 was completed on 3/28/2023. 2) An audit will be performed, by the Unit Coordinators to ensure each resident has a fall risk assessment completed, on admission, after each fall and annually. 3) The Unit Coordinator will perform a quarterly audit of the fall risk assessments to ensure compliance is achieved. Audits will occur quarterly, for the next 3 quarters. 4) The Director of Resident Services will review the quarterly audits and submit to the QA committee, for their review.
Standard #:	22VAC40-73-325-B
Description:	Based on record review, the facility failed to ensure a fall risk rating is completed at least annually, when the condition of the resident changes, and after a fall. Evidence: 1. Upon review of the resident?s record, the last annual fall risk rating for Resident #1 was completed on 09/23/2021.
Plan of Correction:	1) The annual fall risk assessment was completed for resident #1 on 3/28/2023 2) An audit will be performed, by the Unit Coordinators to ensure each resident has a fall risk assessment completed, on admission, after each fall and annually. 3) The Unit Coordinator will perform a quarterly audit of the fall risk assessments to ensure compliance is achieved. Audits will occur quarterly, for the next 3 quarters. 4) The Director of Resident Services will review the quarterly audits and submit to the QA committee, for their review.
Standard #:	22VAC40-73-440-L
Description:	Based on record review, the facility failed to maintain the completed UAI in the resident's record. Evidence: 1. Resident #7?s UAI dated 2/9/2023 indicates the resident requires assistance with bowel and bladder incontinence; however, it does not indicate the type of assistance the resident needs. The UAI for Resident #7 also indicates the resident is disoriented to some spheres all of the time; however, it does not indicate the spheres the resident is disoriented to.
Plan of Correction:	1) The UAI on resident #7, dated 2/9/2023, was been completed to include the two missing items od documentation (bladder/ bowel incontinent assistance and orientation level) on 3/28/2023. 2) An audit will be performed, by the Unit Coordinators to ensure each resident?s UAI is complete and there are no missing items. ? 3) The Unit Coordinator will perform a quarterly audit of the UAI?s to ensure compliance is achieved. Audits will occur quarterly, for the next 3 quarters. 4) The Director of Resident Services will review the quarterly audits and submit to the QA committee, for their review.
Standard #:	22VAC40-73-640-A
Description:	Based on observation, the facility failed to implement their written plan for medication management which includes methods to prevent the use of outdated medications and plan for proper disposal of medication. Evidence: 1. During a review of the medication cart with Staff #1, a bottle of Lisinopril 20 mg tablets for Resident #13 expired 09/30/2022 were observed on the medication cart.
Plan of Correction:	1) The expired medications for resident #13, that were contained in a bag, placed in the bottom of the medication cart for safe keeping until destruction could occur, have been removed and properly destroyed. 2) All medications carts have been audited to ensure there were no other expired medications. 3) Medication cart audits will be performed weekly x 4 weeks, then monthly ongoing to ensure there are no expired medications on the cart. 4) The Director of Resident Services and DON will monitor audit results and present to the QA committee for review.
Standard #:	22VAC40-73-660-A-3
Description:	Based on observation, the facility failed to ensure the individual responsible for medication administration keep the keys to the storage area on their person. Evidence: 1. During a tour of the facility, the medication cart was observed to be unattended with the keys noted on the cart and not on the individual responsible for medication administration.
Plan of Correction:	1) All Licensed nurses and Registered medication aides have been inserviced on community policies and protocols concerning ensuring keys being kept in the possession of the individual responsible for medication administration. 2) Audits will be performed by the DON / DRS to ensure the carts remain locked when not in active use and that keys are in the possession of the licensed nurse or registered medication aide. Audits will occur weekly x 4 weeks, then monthly x 2, then quarterly x 2. 3) Results of audits will be provided to the QA committee, quarterly, for review and determination of need for continuation.
Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure medication be administered in accordance with the physician's or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. The March MAR for Resident #2 does not indicate their 6am dose of Acetaminophen 500mg caplet was administered on 3/4/23, 3/7/23, 3/12/23, 3/18/23, 3/19/23, and 3/22/23. The March MAR for Resident #2 also does not indicate Anti-Fungal 1% Powder and Calmoseptine .44-20.6% Ointment was administered/applied on the night shift on 3/3/23, 3/6/23, 3/11/23, 3/12/23, 3/17/23, 3/20/23, 3/21/23, 3/22/23, and 3/25/23.
Plan of Correction:	1) For preventative, over-the-counter barrier creams that can be performed by direct care staff, the facility will have the documentation occur on the ADL sheets. Any nurse that does not have the ability to access the electronic medical record, will perform the documentation of the medication administration, on a paper record, to ensure appropriate documentation occurs. 2) The unit coordinator will review all Medication Administration Records (MAR?s) to assess for completion of documentation. 3) The Unit Coordinator will perform a monthly audit of the MAR?s to ensure compliance is achieved. Audits will occur monthly x2 then quarterly, for the next 2 quarters. 4) The DRS / DON will review the audits and submit to the QA committee, for their review.
Standard #:	22VAC40-73-700-3
Description:	Based on record review, the facility failed to ensure that only oxygen from a portable source be used by residents when they are outside their rooms. The use of long plastic tether lines to the source of oxygen outside their rooms is not permitted. Evidence: 1. During a tour of the facility, Resident #14 was noted in the common dining area with an oxygen concentrator with long plastic tether line. 2. Staff #7 acknowledged Resident #14 did not have access to a portable source of oxygen to be used outside of their room.
Plan of Correction:	1) The order was obtained and the necessary testing has been performed on resident #14, to allow for the ability to receive portable tanks for her usage. Delivery of a portable oxygen source has occurred. 2) An audit of all residents receiving oxygen will occur to ensure each resident has a portable source of oxygen available, when out of their rooms. 3) The Unit Coordinators will review the list of residents receiving oxygen, monthly x2, then quarterly, for the next 2 quarters, to ensure a portable source of oxygen is available. 4) The DRS / DON will review the audit results and submit to the QA committee, for their review.
Standard #:	22VAC40-73-940-A
Description:	Based on record review, the facility failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Evidence: 1. The last inspection by the appropriate fire official was completed on 04/22/2021.
Plan of Correction:	1) The Annual Fire Inspection was completed by the Deputy Fire Marshal from the City of Va. Beach Fire Department on 3/31/2023. 2) The Maintenance Director will contact the city of Va. Beach Fire Marshal?s office, 2 months prior to the due date, to request the annual inspection be scheduled.