VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Elance at Tuckahoe
567 N. Parham Road
Henrico, VA 23229
(804) 554-3939

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: June 21, 2023

Complaint Related: Yes

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: On 06/21/2023 approximate time 9:33a.m-5:03p.m. On 07/07/2023 approximate time 08:32a.m-6:50p.m The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 04/04/2023 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 70 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the area(s) of non-compliance with standard(s) or law. 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 Angela Rodgers-Reaves Licensing Inspector at (804) 840-0253 or by email at Angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-D
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization must communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each must be included on the individualized service plan. Evidence: Resident #1- The facility records that were submitted for the inspector?s review notes that the resident signed the hospice agreement on 12/13/2022. The resident?s 11/16/2022 ISP that was submitted for the inspector?s review notes in part that the hospice nurse visits weekly and as needed and care aide visits twice weekly. The resident?s 11/16/2022 ISP does not identify a description of services being provided by the hospice agency and is not signed and dated by hospice staff.
Plan of Correction:	FACILITY'S RESPONSE: "Immediate: The Executive Director educate the Director of Health and Wellness on the coordination of hospice services to reflect the coordination of care on the ISP. Director of Health and Wellness reviewed all residents currently receiving hospice services to ensure appropriate coordination is noted within the plan of care. Audit: The Director of Health and Wellness has conducted an audit of current resident charts to ensure ISPs are signed and verified that hospice service recipients? ISPs reflect the hospice service need and signatures. Systemic: The Director of Health and Wellness or designee will review residents who are receiving hospice services weekly to ensure we have an updated hospice plan of care and as such have integrated that into the facility plan of care (ISP) appropriately. Hospice notes will be signed off on by the director of health and wellness weekly to ensure review and coordination. Monitoring: Director of Health and Wellness or designee will monitor new hospice services admission orders to ensure the ISP is updated and accurate. Hospice notes will be signed off on by the Director of Health and Wellness weekly to ensure review and coordination. The Executive Director will randomly audit hospice notes and the care plans of residents receiving hospice services to ensure appropriate coordination."
Standard #:	22VAC40-73-460-H
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that personal assistance and care are provided to each resident as necessary so that the needs of the resident are met, including assistance or care with bathing - at least twice a week, but more often if needed or desired. Evidence: Resident #1 Upon request during the telephone interview on 07/14/2023 facility staff #s 1 and 2 did not submit for the inspector?s review documented evidence that the resident was receiving showers at least two times per week.
Plan of Correction:	FACILITY'S RESPONSE: "Immediate: The Director of Health and Wellness educate Care Givers on the responsibility to provide personal care as needed to include at least two showers/baths a week. Audit: The Director of Health and Wellness or designee audit the shower logs for completion of at least 2 shower/baths per week. Systemic: The Director of Health and Wellness or designee will ensure all showers/baths are provided each week through the audit of completion of at least 2 shower/baths a week for residents documented on shower log. This will be completed at least twice weekly. The Director of Health and Wellness or designee will review the shower schedules and shower sheets to ensure the appropriate showers are given as directed by the plan of care twice monthly, appropriate updates and notifications will be made. Monitoring: Director of Health and Wellness or designee will audit the Anthology Skin Integrity form to the shower schedule to ensure compliance."
Standard #:	22VAC40-73-700-2
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted the facility staff the facility failed to ensure that when oxygen therapy is provided, all direct care staff responsible for assisting residents who use oxygen supplies have had training or instruction in the use and maintenance of resident-specific equipment. Evidence: Resident #1 During the review of facility records and upon request during the 06/21/2023 onsite interview with facility staff #3 the facility did not submit for the inspector?s review documentation that facility staff had received oxygen training.
Plan of Correction:	FACILITY'S RESPONSE: "Immediate: The Director of Health and Wellness educate Care Providers on the use and understanding of oxygen equipment and supplies. Audit: The Business Office Director audit employee files of Care Providers for completion of oxygen equipment and supplies training. Systemic: The Director of Health and Wellness has provided in?service training to all Care Providers on oxygen equipment and supplies. This will be ongoing with new hire and completed semi-annually. Monitoring: Business Office Director or designee will audit employee files of Care Providers for completion of training following orientation and semi-annually ensure appropriate education and training."