VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Stuarts Draft Christian Home
144 Patton Farm Road
Stuarts draft, VA 24477
(540) 932-3050

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Jan. 13, 2020 and Jan. 14, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Answered questions and made recommendations in the following areas: 1) Discussed the time frame food consumption logs must be completed after each meal - best practice is to complete each resident's log sheet as the plate is collected. 2) One of five oxygen orders needed clarification on the source - ensure this clarification is completed for resident A. 3) Rather than completing a separate form for infection control reviews, add this information to the volunteer orientation form that is currently being completed. 4) Recommended developing a tracking system to ensure staff obtain all of the required dementia training hours within the required time frames. 5) Discussed that training on residents with mental impairments may include mental health and dementia training for the required annual training hours. 6) Implement a procedure to check the hot water temperature in various rooms at various times of the day to ensure compliance. 7) Discussed completing annual sworn statements (rather than annual criminal record checks) in order to ensure current staff have not been convicted of a barrier crime. These are due by the end of January 2020. 8) Discussed the need for hospice to clarify the multiple pain medication orders for residents and to specify what to give when and for what specific symptoms, as medication aides can not assess mild, moderate and severe pain. 9) Sex offender registry reviews were completed annually according to interviews; however, the form that lists the sex offender registry review needs to be clarified to reflect the wording in standard 350.C. 10) When the hospice agency signs the updated agreement, please scan a copy to this inspector for review. 11) This licensing inspector will review the updated policies submitted and notify administrator of any needed changes or recommendations. 12) Clarified with the administrator what types of incidents must be reported - including any time a resident must be sent to the hospital, anytime 911 is called, anytime a resident has a dermal ulcer that is a stage two or above, any injuries of unknown cause, and any incident that threatens the life, health and safety of a resident.

Comments:

An unannounced renewal inspection was conducted on 1/13/20 from 7:20 am to 5:45 pm and on 1/14/20 from 7:40 am to 5:00 pm. Upon arrival, there were 29 residents in care and five staff on duty. A tour was immediately conducted and all of the required postings were in place. The facility was clean and free from any foul odors. The current menu and activities calendar accurately reflected this inspector's observations and the special diets observed were served according to the physicians' orders. Individual interviews were conducted with residents, family members and staff. Medication administration observations were completed for four residents with one registered medication aide. The medication administration records, physicians' orders and medications were reviewed for all four residents. Criminal record checks were reviewed for all current staff hired since the last inspection. Six resident, one volunteer, two contract and three staff records were reviewed. Selected sections of six additional residents and 15 staff records were also reviewed. The areas of noncompliance included disclosure form, first aid training, initial physicals, sex offender registry checks, communication with the mental health provider, medication availability, hot water temperature and dementia training. Staff answered all questions and obtained all information requested. Thank you for your cooperation and assistance during this inspection.

Violations:

Standard #:	22VAC40-73-1030-B
Description:	Based upon record reviews and interviews, the facility failed to ensure five of five direct care staff records reviewed had documentation of completion of six hours of dementia training within the first four months of starting work. Evidence: 1) Staff A (hired 7/29/19) completed 2.25 hours, H (hired 9/3/19) completed two hours, J (hired 9/18/19) completed 2.75 hours, K (hired 3/26/19) completed 4.25 hours and L (hired 6/21/19) completed 2.75 hours. 2) On 1/14/20, the LI interviewed the administrator and staff N and both stated these were the only dementia training hours these staff had completed
Plan of Correction:	A log is being created to ensure dementia training is being completed. All new hire dementia training will now be done during the orientation process. The assistant to the director of nursing (DON) is responsible for ensuring this training is done by maintaining the log and having staff complete training. The administrator will conduct random audits of staff training to ensure the training is completed as required.
Standard #:	22VAC40-73-1030-D
Description:	Based upon record reviews and interviews, the facility failed to ensure two of the two non-direct care staff records reviewed had documentation of completing two hours of dementia training within the first month of hire. Evidence: 1) Staff B (hired 10/28/19) had not completed any dementia training and staff M (hired 5/2/19) had completed 1.75 hours of dementia training. 2) On 1/14/20, the LI interviewed the administrator and staff N and both stated this was the only training that was completed for the two staff.
Plan of Correction:	A log is being created to ensure dementia training is being completed by non-direct care staff. All new hire dementia training will now be done during the orientation process. The assistant to the DON will be responsible for ensuring this training is completed. The administrator will conduct random audits of staff training to ensure compliance with this standard.
Standard #:	22VAC40-73-50-A
Description:	Based upon documentation and an interview, the facility failed to ensure the most current disclosure form was provided and on file for two of the six residents' records reviewed. Evidence: 1) Residents C (admitted 12/18/19) and F (admitted 12/6/19) did not receive the new disclosure that included information regarding the facility's availability and operation of a generator. 2) On 1/14/20, the LI interviewed the administrator who stated they had not implemented the newest model form.
Plan of Correction:	The updated disclosure form that includes initials on each page, along with the generator information, has been implemented. The DON will ensure the newest disclosure form is used for all new admissions. All current residents will be given the newest form to initial and sign and a copy of the form and acknowledgement of receipt will be maintained in each resident's file.
Standard #:	22VAC40-73-260-A
Description:	Based upon record reviews, the facility failed to ensure one of the five staff reviewed completed first aid training within 60 days of hire. Evidence: 1) Staff A (hired as a direct care aide on 8/9/19) did not complete first aid training until 11/7/19. 2) On 1/14/20, the LI interviewed the administrator who stated she was not sure why staff A did not complete the first aid training within the required time frame.
Plan of Correction:	The DON will ensure cardiopulmonary resuscitation (CPR) and first aid training are obtained within the required time frames. All new hire CPR and first aid training will be completed within the first 60 days of hire. If the class is full, then the local emergency response agency will provide the training. The administrator will conduct random audits of new staff training records to ensure compliance with this standard.
Standard #:	22VAC40-73-320-A
Description:	Based upon documentation and an interview, the facility failed to ensure all required information was obtained on the initial physicals for four of the six residents' records reviewed. Evidence: 1) The initial physicals for residents A (admitted 10/15/18 and completed 10/14/18), C (admitted 12/18/19 and completed 12/13/19 ), E (admitted 8/16/19 and completed 8/15/19) and F (admitted 12/6/19 and completed 12/2/19) did not include the allergic reactions to the allergies that were listed on the physicals. There was also no documentation in the residents' records that indicated staff followed up to obtain this information 2) On 1/13/20, the LI interviewed the administrator who stated the information was not on file.
Plan of Correction:	The DON will review each initial physical prior to admission, as part of the admission process, to ensure that all reactions to allergies are listed on the physical form. The missing information for residents A, C, E and F has been obtained. The assistant DON will review the initial physicals to ensure compliance with this standard.
Standard #:	22VAC40-73-350-B
Description:	Based upon documentation and an interview, the facility failed to ensure sex offender registry checks were on file for two of the six residents' records reviewed. Evidence: 1) Residents E (admitted 8/16/19) and F (admitted 12/6/19) did not have documentation on file of completion and review of a sex offender registry check. 2) On 1/13/20, the licensing inspector (LI) interviewed the administrator who stated the sex offender registry checks were not on file for residents E and F.
Plan of Correction:	Business office will complete a sex offender background check when a new admission is added to the billing system and prior to admission. This process will be done as part of the admission process. Sex offender checks were obtained for residents E and F and an audit was completed to ensure all current residents had a completed sex offender check on file. The administrator will ensure compliance with this standard.
Standard #:	22VAC40-73-510-B
Description:	Based upon record reviews and an interview, the facility failed to ensure communication procedures were implemented with the one mental health provider for the only resident receiving services. Evidence: 1) Resident I was seen by a mental health provider on 4/23/19, 5/8/19, 10/10/19, 12/19/19, and 1/8/20; however, there were no progress notes on file or any documentation to ensure the mental health needs of the resident were being met. 2) On 1/13/20, the LI interviewed the administrator who stated there was no information on file regarding progress notes or contact with the mental health provider.
Plan of Correction:	The administrator will obtain progress notes following each visit with the mental health provider. The mental health agreement has been updated, signed and filed to reflect this requirement. The progress notes for resident I were obtained while the inspector was here.
Standard #:	22VAC40-73-680-M
Description:	Based upon observations and an interview, the facility failed to ensure one of four residents medications were available at the facility. Evidence: 1) Resident A had an order for Triamcinolone Cream and Nitroglycerin; however, during the cart audit on 1/13/20, neither of these medications were observed in the cart. 2) On 1/13/20, the LI interviewed the medication aide on duty, staff P, and she also checked the cart and resident's room and stated the medications were not found. Staff P stated she had administered the medication that morning but had no idea where it was now located. 3) The January medication administration record indicated the Triamcinolone Cream had been administered that morning by staff P.
Plan of Correction:	A weekly check will be done by the assistant to the director of nursing (DON) to ensure all medications are in the cart and available. A review will be done with all registered medication aides (RMAs) on 2/6/2020 regarding this requirement. The administrator will conduct random cart audits to ensure compliance with this standard.
Standard #:	22VAC40-73-860-G
Description:	Based upon observation and interviews, the facility failed to ensure the hot water temperature was maintained within a range of 105 degrees Fahrenheit (F) to 120 degrees F. Evidence: 1) On 1/14/20, the LI tested the hot water temperature at the sink in resident C's bathroom and the thermometer registered 133.4 degrees F. 2) On 1/14/20, the LI interviewed residents and one resident stated the hot water temperature was too hot.
Plan of Correction:	A weekly log will be created to monitor water temperatures in various rooms in each hall. Maintenance will be notified immediately for any temperatures not within the range of 105 degrees F to 120 degrees F. The DON will ensure compliance with this standard.