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 27, 2024

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:

22VAC40-73-550

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: 03/27/2024 from 8:40 am to 4:30 pm. 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: 80 Number of resident records reviewed: 7 Number of staff records reviewed: 4 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4 Observations by licensing inspector: Breakfast and an activity were observed. A medication pass observation was completed for 4 residents. The following were reviewed: resident and staff records, medication carts, and water temperatures. 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 #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #2 works as direct care staff and does not have a current certification in first aid.
Plan of Correction:	1) Staff #2 is scheduled to take First Aid training on 4/12/2024. 2) An audit of the direct care staff members files will be performed to assess for current First Aid certification. Those not in compliance will be scheduled for the next available class. 3) The community will schedule First Aid training courses, monthly as employees are coming due for recertification. 4) The Director of Nursing, or designee, will review the direct care staff member list, monthly, to determine who is due for their First Aid renewal course and have them scheduled, accordingly.
Standard #:	22VAC40-73-450-E
Description:	Based on record review, the facility failed to ensure the individualized service plan be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative when reviews and updates of the plan have been made. Evidence: 1. The ISPs for Resident #5 (updated 3/22/2024) and Resident #6 (updated 03/07/2024) were both updated; however, they were not signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative.
Plan of Correction:	1) The Individualized Service Plans (ISP?s) for residents #5 and #6 have been signed and dated, by the team member completing the update and have been reviewed with the resident?s RP. The RP?s have been requested to sign-off on these updates, upon their next visit to the community. 2) An audit will be performed, by the Unit Coordinators to ensure each resident?s ISP has the appropriate signatures and dates for any updates that have been performed. 3) The Unit Coordinator will perform audits to ensure updates have appropriate signatures and dates. The audits will occur weekly x4, then monthly x3. 4) The Director of Nursing, or designee, will review the 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. The following expired medications were observed in the medication carts at the facility: PRN Docusate Sodium 100 mg capsules expired 02/29/2024 for Resident #9, 2 cards of Quetiapine Fumarate 25 mg tablets both expired 11/30/2023 for Resident #10, and PRN Ondansetron 4mg tablets expired 11/30/2023 for Resident #11.
Plan of Correction:	1) The expired medications for residents #9, #10 and #11 were removed from the carts and were properly destroyed on 3/27/2024. 2) All medications carts have been audited to ensure there were no other expired medications. 3) Medication cart audits will be performed weekly x4, then monthly x3 to ensure there are no expired medications on the carts. The cart audits will be performed by a peer or manager. 4) The Director of Nursing, or designee, will monitor audit results and present to the QA committee for review.
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. Resident #6 has an order to administer Muro-128 5% ointment 2 times daily to the left eye. Resident #6?s March MAR shows the AM dose was changed from 6 am to 9 am on 03/20/2024; however, the 6 am dose was never discontinued. 2. The March MAR for Resident #6 shows the resident has received the ointment 3 times daily since 03/20/2024.
Plan of Correction:	1) The medication administration time for resident #6?s Muro-128 5% was clarified and corrected by the Unit Coordinator, on 3/27/2024. 2) Each unit coordinator will perform an audit to review the Physician Orders against the Medication Administration Records (MAR) to assess for accuracy in the orders and on the MAR. 3) The 11-7 nurse, will check physician orders, against the MAR for completion and accuracy, nightly. The Unit Coordinator will perform an audit of Physician orders against the MAR to ensure compliance with accuracy is achieved. Audits will occur weekly x4, then monthly x3. 4) The Director of Nursing, or designee, will review the audits and submit to the QA committee, for their review.