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: March 29, 2022 and March 30, 2022

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 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

Technical Assistance:

1. Ensure individualized service plans (ISPs) specify the services being provided by staff as well as outside agency staff (including hospice). Just listing the agency does not indicate the specific services they provide. 2. Answered questions about residents who only self-administer one or a portion of their medications and how to document this information on the uniform assessment instrument. 3. Ensure the resident signs the orientation form and not just the legal representative (if the resident is cognitively impaired). 4. Ensure first and last names of residents are written on all over-the-counter medications - not just the resident's initials. 5. Recommended adding a statement to the ISP form that resident was given a copy of the ISP and have the resident sign and date it. (Interviews revealed copies were being given). 6. Send a copy of the new emergency evacuation drawing once it has been completed.. .

Comments:

An unannounced monitoring inspection was conducted on 3/29/2022 from approximately 8:15 am to 5:10 pm and 3/30/2022 from approximately 10:15 am to 4:25 pm. Upon arrival there were four staff on duty and 22 residents in care. A tour was immediately conducted of the interior and exterior of the facility. The facility was clean and free from any foul odors. The posted menu and activities calendar were current and accurately reflected this inspector's observations. Medication administration observations were completed with one nurse for five residents. The March 2022 medication administration records, signed physicians' orders and medications were reviewed for all five residents. Five resident, one discharge, three staff and two contract staff records were reviewed. Selected sections of four additional resident and three staff records were also reviewed. The criminal record reports for all current staff hired since the last inspection were reviewed. Individual interviews were conducted with residents and staff. The areas of noncompliance included reporting major incidents, first aid training, posting a list of current staff with first aid and cardiopulmonary resuscitation, posting name of staff in charge, written assurance, individualized service plans and emergency preparedness and response training. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-70-C
Description:	Based upon documentation and an interview, the facility failed to ensure major incident reports were received within seven days of the incident. Evidence: 1. Incident involving resident 8 occurred on 7/4/2021 and the full report was received on 9/30/2021. 2. Incident involving resident 12 occurred on 8/4/2021 and full report was received on 8/12/2021. 3. Incident involving resident 11 occurred on 8/8/2021 and full report was received on 9/28/2021. 4. Incident involving resident 10 occurred on 8/28/2021 and full report was received on 9/28/2021. 5. Incident involving resident 9 occurred on 8/29/2021 and full report was received on 9/20/2021. 6.Incident involving resident 7 occurred on 1/8/2022 and full report was received on 1/20/2022. 7. Incident involving resident 2 occurred on 3/5/2022 and full report was received on 3/21/2022. 8. Home health nursing notes beginning on 11/17/2021 through 12/17/2021 and 2/23/2022 through 3/23/2022 document wound care to bilateral buttocks. A report was not submitted on either of these two wounds. 9. On 3/30/2022, the LI interviewed the administrator who stated these reports were not submitted as required.
Plan of Correction:	All future major incident reports will be submitted within seven days of incident. Administrator has implemented a major incident tracking form to help with this process. Administrator will ensure these are done.
Standard #:	22VAC40-73-260-A
Description:	Based upon record reviews and an interview, the facility failed to ensure one of four staff records reviewed had documentation of completion of first aid (FA) within 60 days of hire. Evidence: 1. Staff 2 (hired 9/24/2021) did not have documentation of FA certification. 2. On 3/29/2022, the LI interviewed the administrator who stated staff 2 had not completed the FA training.
Plan of Correction:	All staff have received the needed CPR/First Aid. New staff have been added to the posted CPR/First Aid list. Administrator will ensure all new hires receive training within 60 days. New hire checklist implemented
Standard #:	22VAC40-73-260-C
Description:	Based upon observations, documentation and an interview, the facility failed to ensure the posted list of staff with current FA and cardiopulmonary resuscitation (CPR) certifications was kept current. Evidence: 1. On 3/29/2022, the LI observed the posted list of staff with current FA and CPR certifications and staff 9 was listed but was no longer employed. 2. staff 10 was not listed; however, she was a current employee who was certified in CPR. 3. The posted list was last updated on 2/2022, according to the date at the bottom of the list. 4. On 3/29/22, the LI interviewed the administrator who stated the list was not current as stated above.
Plan of Correction:	Posted list is now current. Administrator will ensure current list is up-to-date and posted. Administrator has implemented a new hire check off list to help with this process.
Standard #:	22VAC40-73-290-B
Description:	Based upon observations and an interview, the facility failed to ensure the name of the current on-site person in charge was posted Evidence: 1) On 3/29/2022 at approximately 8:20 am, the LI observed staff 11's name posted on the dry erase board at the nurses' station as the staff in charge. 2) On 3/29/2022, the LI interviewed staff 1 who stated she had forgotten to update the name of the staff in charge on the board. 3) On 3/29/2022, the LI interviewed staff 11 who stated she last worked second shift and left at 11:00 pm on 3/28/2022.
Plan of Correction:	All registered medication aides (RMAs) have been reminded to change the white board to their name as soon as they clock in. RMA on duty will ensure this process is done. Signage was placed at time clock as a reminder./
Standard #:	22VAC40-73-310-D
Description:	Based upon record reviews and an interview, the facility failed to ensure two of the six residents reviewed received written assurance. Evidence: 1. Resident 2 and 4 had no documentation of written assurance on file. 2. On 3/29/2022, the LI interviewed the administrator who stated she must have forgotten to complete the written assurance for residents 2 and 4 as she checked both records and could not find them.
Plan of Correction:	Administrator will ensure most recent updated correct form is being used for written assurance. Resident 2 and 4 now have written assurance on file. Administrator has implemented a new admission check off list to help with this process.
Standard #:	22VAC40-73-450-B
Description:	Based upon documentation and an interview, the facility failed to ensure four of the six individualized service plans (ISPs) reviewed included all needs and services provided. Evidence: 1. The uniform assessment instrument (UAI) completed 7/20/2021 for resident 1 indicated physical and mechanical assistance were needed for wheeling; however, the ISP completed 7/20/2021 did not include wheeling. 2. Resident 1's physician's order for hospice services was signed 3/16/20212; however, the specific services provided by hospice were not listed. 3. Resident 3's ISP signed 2/18/2022 listed wound care; however, the specific services provided by outside agency staff and facility staff were not listed. 4. Resident 4's UAI completed 10/29/2021 indicated mechanical assistance needed for toileting and wheeling; however, the ISP completed 11/3/2021 listed resident as independent with toileting and did not list wheeling. 5. Resident 4 had a signed physician's order for a cardiac diet; however, this need was not listed on the ISP completed 11/3/2021. 6. Resident 5 had signed physician's orders to self-administer multiple over-the-counter medications; however, the ISP completed 2/26/2022 listed medications to be administered by staff. 7. On 3/30/2022, the LI interviewd the administrator who stated these needs were not listed on the ISPs.
Plan of Correction:	1) UAI was corrected on 3/31/22. 2) ISP was updated with specific hospice services. 3) ISP was updated with wound care clarification. 4) ISP was corrected. UAI was corrected. 5) ISP was corrected. 6) The ISP completed 2/26/22 did include the listed meds for self-medication. 7) Home health wound care and hospice services will be more specific to include exactly what services are provided. Nurse will thoroughly compare UAI to ISP needs for accuracy. UAI manual was printed and will be used to aid with proper completion of UAIs each time. The administrator will review prior to signing to ensure all information is accurate and complete.
Standard #:	22VAC40-73-950-E
Description:	Based upon documentation and an interview, the facility failed to ensure the emergency preparedness and response plan (EPRP) was reviewed with all residents at least once every six months. Evidence: 1. The only EPRP review with residents was dated as completed on 12/1/2021 on the training sign in sheets. 2. On 3/29/2022, the LI interviewed the administrator who stated the only training conducted with residents on the EPRP this past year was 12/1/2021.
Plan of Correction:	The next training with residents on the EPRP is scheduled for June 2022. The administrator will ensure this training is done every six months as required. This training will be kept on the calendar as a reminder.