VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Humphrey's Retirement Home
3405 Chamberlayne Avenue
Richmond, VA 23227
(804) 329-1316

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Sept. 11, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This complaint investigation was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. The complaint investigation was initiated on 09/11/2020 and concluded on 11/02/2020. The facility Administrator was contacted by telephone to initiate the inspection. The facility Administrator reported that the current census was 22. The inspector emailed the facility Administrator a list of items required to complete the investigation. The information gathered during the complaint investigation and interviews conducted determined non- compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. It has been determined that the complaint is valid. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact me at (804)662-9774 or angela.r.reaves@dss.virginia.gov. if further assistance is needed.

Violations:

Standard #:	22VAC40-73-340-C
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that if the individual is admitted the psychosocial and behavioral history is used in the development of the person's individualized service plan and documentation of the history shall be filed in the resident's record. EVIDENCE: Resident #1-. 03/01/2019- initial discharge from the facility. 12/20/2019- Documented date of readmission - The resident was readmitted to the facility from a private home. During interviews the facility Administrator verbalized her knowledge of the mental health history for resident #1. Facility staff #1 assessed the resident using the Uniform Assessment Instrument (UAI) on 12/20/2019 documenting that the resident was not in need of a psychiatric or psychological evaluation. The facility did not submit upon request documented evidence that a plan of care had been discussed or developed with mental health professionals and family members based on the resident?s history of mental illness and behavioral disorders.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-440-H
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that reassessment was conducted due to a significant change in the resident's condition to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. EVIDENCE: Resident #1-Documented Date of Admission 12/20/2019 The resident?s Uniform Assessment Instrument (UAI) dated 12/20/2019 notes the resident to have appropriate behavior patterns and that the resident was oriented in all spheres. The facility?s ?Communication Documentation Mental Health? document received at the licensing office from the facility Administrator on 09/18/2020 notes that the resident is ?extremely manic with increasingly more aggressive behaviors.? During interviews the facility Administrator clarified and stated that the document was sent to a licensed health care provider (identified) on 07/12/2020. Facility records that were submitted for the inspector?s review revealed that beginning 12/2020 - 09/2020 resident #1 was not administered over100 dosages of prescribed medications. During interviews the facility Administrator verbalized her knowledge of the resident being noncompliant with the prescribed medication regimen as well as consistently violating facility house rules. The facility did not submit upon request documented evidence that the resident had been reassessed to determine whether a psychiatric of psychological evaluation was needed or whether an alternative placement was in the best interest of the resident.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-460-C
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that care was furnished in a way that fosters the independence of each resident and enables him to fulfill his potential. EVIDENCE: Resident #1- Documented Date of Admission-12/20/2019 Resident #1 was readmitted to the facility after being discharged; per facility documentation on 03/01/2019. The complainant alleges that the facility is not providing adequate supervision for resident #1 and that basic needs are not being met. Facility records and interviews conducted revealed the following: ?Requested facility Medication Administration Records (MARs) charting for 12/2019-09/08/2020 that were submitted for the inspector?s review revealed that that the resident was not compliant with his medication administration program. ?12/2019; facility staff documented that the resident was not administered twenty-five (25) dosages of medications. The resident?s 12/2019 ISP that was submitted for the inspector?s review in part notes Resident identified "is medication compliant?. ?04/2020; twenty dosages of medications were not administered. ?05/2020; Twenty four dosages of medications were not administered. The resident?s 05/24/2020 ISP that was submitted for the inspectors? review in part noted that the resident was inconsistent with medication compliance. Facility staff documented the goal as ?Continuous stabilization and decrease hospitalization and shifts in personality.? ?06/2020; twenty dosages of medications were not administered. ?07/2020; Thirty four (34) dosages of medications were not administered. The facility Administrator clarified that the undated ?Communication Documentation Mental Health? document that was submitted for the inspector?s review and notes that the resident was not taking his medications consistently and was ?extremely manic with increasingly more aggressive behaviors and undertone? was sent to a licensed health care professional (identified) on 07/12/2020 after eight months of the resident not being medication compliant. ?08/2020; Fifty two (52) dosages of medications were not administered. ?09/08/2020 -Resident #1 agreed to and was admitted to a local hospital for an inpatient psychiatric admission. During interviews the facility Administrator reported that the resident had a physical altercation with a staff member resulting in emergency intervention. The facility Administrator stated during interviews that prior to 07/12/2020 the resident was involved with a supportive services agency (identified) but did not submit upon request any documentation of the specific services that were requested and that the resident received. For eight months the facility allowed the resident to remain in care without a documented plan of care that identified a specific program of care that allowed the resident to maintain and function at his full capabilities.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-470-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted the facility failed to ensure that either directly or indirectly, that the health care service needs of residents are met. EVIDENCE: Resident #1- Documented Date of Admission 12/20/2019 While the facility Administrator verbalized her knowledge of the resident?s noncompliance with medication administration as well as the resident?s history of mental illness, the facility however did not submit upon request documented evidence that mental health services were sought out and obtained for resident #1 prior to July 2020. Upon request the facility did not submit for the inspectors? review documented evidence that the resident?s physician was notified that the resident had not been medication compliant since 12/2020, informed the physician of the observed behaviors and received documented guidance to assist with an alternative plan of action that ensured that the compliance.
Plan of Correction:	Not available online. Contact Inspector for more information.