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. 9, 2021 , Sept. 10, 2021 , Sept. 13, 2021 and Sept. 14, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-80 THE LICENSE.

Comments:

A renewal inspection was initiated on September 8, 2021 and concluded on September 14, 2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 24. The inspector emailed the Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, activities calendars, menus, health and fire inspections, healthcare oversight, dietary and pharmacy oversights, and fire drills submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on September 10, 2021. An exit interview was conducted with the Administrator on September 14, 2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-490-D
Description:	Based on record review and interview with staff, the facility failed to ensure the licensed health care professional who provided the health care oversight met the subsection including requirements of subsection B and that the requirements were in writing. Evidence: 1. The health care oversight dated 7-24-2021 did not address subsection B including the following items on the oversight: Ascertain whether a resident's service plan appropriately addresses the current health care needs of the resident; Monitor direct care staff performance of health-related activities; Evaluate the need for staff training; Provide consultation and technical assistance to staff as needed; Review documentation regarding health care services, including medication and treatment records, to assess that services are being provided in accordance with physicians' or other prescribers' orders; Monitor conformance to the facility's medication management plan and the maintenance of required medication reference materials; Evaluate the ability of residents who self-administer medications to continue to safely do so; Observe infection control measures and consistency with the infection control program of the facility. 2. Staff #1 confirmed there were no comments left on the health care oversight to document what was addressed as required and in writing.
Plan of Correction:	The Administrator will have the health care professional to review notes and complete the health care oversite in its entirety; to include comments that address the questions in subsection B.
Standard #:	22VAC40-73-640-A
Description:	Based on record review, observation, and interview with staff, the facility failed to ensure methods to ensure accurate counts of all controlled substances. Evidence: 1. During a medication cart audit on 9-10-2021, Resident #1?s Lorazepam 1 mg contained one extra pill then was supposed to be in the packet. 2. The facility?s medication management plan documented, ?Count the number of pills in each container and confirm that the number of pills in the container is the same as the number on the client.? 3. Staff #1 confirmed that the incorrect number of medications was seen, as there was documented 10 pills but 11 in the packet.
Plan of Correction:	The Administrator will follow the medication management plan by counting all the pills in the container and comparing it to the number on the package as well as documenting errors or correction.
Standard #:	22VAC40-73-870-A
Description:	Based on observation and interview with staff, the facility failed to ensure the interior and exterior of all buildings were maintained in good repair and kept clean and free of rubbish. Evidence: 1. During the onsite inspection conducted on 9-10-2021, the following was observed not in good repair nor kept clean and free of rubbish as evidenced by the photographs taken: a. The downstairs shared bathroom contained a loose slab of material leaning against a wall to the left of the toilet covering a hole in the wall. b. A maintenance/storage closet on the second floor had a broken lock with exposed nails protruding out from the door. c. Outside on the grounds, directly outside of a set of four stairs on the backside of the facility were piles of wood, scrap pieces of metal, rusted paint cans, broken furniture, and garbage bags. d. On the back porch on the second floor, the ceiling of the porch was missing leaving an approximately 1 foot long exposed part of ceiling open. 2. Staff #1 confirmed during onsite interview the aforementioned areas were not in good repair nor kept clean and free of rubbish.
Plan of Correction:	Humphrey home is in the process of removing, breaking down, and hauling off furniture and unused equipment. The pile of debris has been removed and going further the Administrator will use caution tape to secure the area. The Administrator will maintain the upkeep of the area by painting and resealing the opening back of the tub. The Administrator had Maintenance to cover the opening on the back porch ceiling. The Administrator will replace frame and door to look more aesthetically pleasing.
Standard #:	22VAC40-80-120-E-1
Description:	Based on observation and interview with staff, the facility failed to ensure certain documents related to the terms of the license were posted on the premises of each licensed facility including the most recently issued license and the findings of the most recent inspection of the facility; Evidence: 1. During the on-site inspection on 9-10-2021, the license posted expired on 10-24-2020. Additionally, the most recent findings from the inspection dated 10-13-2020 were not posted. 2.Staff #1 confirmed during interview the required postings were not posted on-site on the date of the inspection.
Plan of Correction:	Administrator will make sure all postings are properly displayed on the board.