VIRGINIA DEPARTMENT OF SOCIAL SERVICES

WoodHaven At Williamsburg Landing
5500 Williamsburg Landing
Williamsburg, VA 23185
(757) 253-0303

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: May 20, 2020 , May 22, 2020 , May 26, 2020 and May 28, 2020

Complaint Related: No

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

This inspection 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. A renewal inspection was initiated on 5-20-20 and concluded on 5-26-20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 95. The inspector e-mailed the administrator a list of items required to complete the inspection. The inspector reviewed 5 resident records, 5 staff records, staff schedule, healthcare oversight, health department inspection, fire and emergency drills, oversight by dietitian/nutritionist and new hire since last renewal inspection ( date of hire, sworn statement/affirmation and criminal history record report. 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 #:	22VAC40-73-120-B
Description:	Based on document review and staff interview, the facility failed to ensure one of five staff completed all of the required oriented requirements per the regulation. Evidence: 1. During the remote inspection, a review of staff #6?s training document submitted on 5-22-20 did not include documentation of orientation training. A review of training documents submitted on 5-26-20 did not documentation of the following orientation: (a) the purpose of the facility, (b) the facility?s organizational structure, (c) the services provided and (d) the daily routines. 3. On 5-21-20 staff training received from initial request. On 5-26-20, during telephone conversation with staff #1, additional orientation/training information requested and received for staff #6. 3. A review of documents submitted during the remote inspection revealed staff #6?s training document submitted on 5-22-20 and 5-26-20 did not include documentation of the following: (a) the purpose of the facility, (b) the facility?s organizational structure and (c) the services provided
Plan of Correction:	22VAC40-73-(3)-120-B. Based on document review and staff interview: Staff #6 training document submitted on 5-26-20 did not include (a) the purpose of the facility, (b) the facility's organizational structure and (c) the services. These items are now included in all new hire orientation. All new staff in all departments that work in Assisted Living will have the DSS orientation form which includes all requirements outlined in regulations. This procedure is part of in processing for all new employees and completed by the Department Leaders.
Standard #:	22VAC40-73-120-C
Description:	Based on document review and staff interview, the facility failed to ensure one of five staff completed all of the required initial training per the regulation. Evidence: 1.During the remote inspection, staff #6 training documents submitted on 5-22-20 and 5-26-20 did not include documentation of the following initial training: (a) procedures for handling of resident?s emergencies, (b) use of the first aid kit and knowledge of its location and (c) confidential treatment of personal information. The following orientation documents were submitted: (a) Acknowledgement of Regulatory training, signed and dated 1-7-20, (c) Relias training record and (c) Housekeeper's Orientation Checklist signed and dated 1-3-10 with staff #6's date of hire noted 12-19-19.
Plan of Correction:	22-VAC-40-73-(3)-120-C: Based on document review and staff interview: Staff #6 training document submitted on 5-26-20 did not include training: (a) procedures for handling of emergencies, (b) use of first aid kit and knowledge of its location and (c) confidential treatment of personal information. These items are now included in all new hire orientation. All new staff in all departments that work in Assisted Living will have the DSS orientation form which includes all requirements outlined in regulations. This procedure is part of in processing for all new employees and completed by the Department Leaders.
Standard #:	22VAC40-73-280-E
Description:	Based on document review and staff interview, the facility failed to ensure it did not allow individuals to work in a position that involves direct contact with a resident until a background check has been received as required in the Regulation for Background Checks for Assisted Living Facilities (22VAC 40-90) unless under the supervision of another employee with a completed background check which meet the requirements of the background check regulation. Evidence: 1. During the remote inspection, a review of private duty documents submitted on 5-22-20 for staff #PD-1 and #PD-2?s criminal background check was from a local police station. The aforementioned individuals provided activities of daily living (adl) tasks for resident #1. 2. A review of the new staff hires, since the facility?s last inspection document submitted on 5-19-20 and additional documents received on 5-21-20, noted staff #NH-1?s date of hire was 3-2-20. Clarification regarding staff date of hire was requested on 5-26-20. Staff NH-1?s criminal background check was dated 1-20-20 and the sworn disclosure date was noted 12-28-19.
Plan of Correction:	22-VAC-40-73- (4)- 280-E. 1. PD#1 and PD#2 did not have State Police criminal background check as regulation require prior to direct contact with resident #1. All required paperwork has been obtained as required by DSS regulations. Plan moving forward is that no one will be allowed to have direct contact with our residents without the required paperwork. All private duty companies have been alerted of this required regulation prior to sending a new staff member. Resident Service Coordinator and Resident Admissions Coordinator are points of contact for these requirements. 2. NH #1 criminal background check was dated 1-20-20 and the sworn disclosure was noted 12-28-19. Moving forward when a new employee's date of hire is different than signed paperwork an addendum will be added to file with start date. This procedure is handled by Talent Management.
Standard #:	22VAC40-73-310-H
Description:	Based on document review and staff interview, the facility failed to ensure it did not admit or retain individuals with any prohibitive conditions or care needs. Evidence: 1. During the remote inspection, resident #2's record submitted on 5-21-20 noted psychotropic medications, Celexa, without a treatment plan. Following a request on the morning of 5-26-20, Clonazepam treatment plan was submitted on 5-26-20 with a document date of 1-29-20, however, the treatment plan was not signed and dated by a prescriber. This medication was also noted on the resident's admitting physical examination dated 1-28-20. 2. A review of resident #4's record submitted on 5-21-20 noted psychotropic medications, Divalproex, Ativan, Zoloft, Buspirone and Haloperidol. Following request made on the morning of 5-26-20, treatment plans with a date of 3-17-20 was submitted the afternoon of 5-26-20. The treatment plans submitted were not dated and signed by a prescriber.
Plan of Correction:	22-VAC 40-73-(5)-310-H. Resident #2 record: the treatment plan was not signed and dated by a prescriber and medication was noted on the resident's admitting physical examination dated 1-28-20. Resident #4 record: the treatment plan was not signed and dated by prescriber. Resident #2 and #4 records for treatment plans have been corrected. Plan moving forward is that the Manager of Assisted Living and Memory Support will check their dashboards daily and forward information to Nurse Practioner to ensure treatment plans are dated and signed as required by regulations. Weekly reports will be run to ensure all treatment plans are signed and dated for final checks and balance.
Standard #:	22VAC40-73-450-C
Description:	Based on document review and staff interview, the facility failed to ensure the comprehensive included all assessed needs. Evidence: 1. During the remote inspection, a review of resident #1's uniformed assessment instrument (uai) dated 12-16-19 noted stairclimbing not performed, however, the individualized service plan (ISP) dated 12-71-29, did not document what services staff for provide for the assessed need. Resident #1's April 2020 medication administration record (mar) and physician's order noted resident self-administers "Ocu-soft lid scrub to both eyes two times a day" and Meclizine, as needed (prn). However, the residents uai noted facility staff administers medication and the ISP did not indicate resident's self-administration. The ISP also did not indicate medication administration assessed need. 2. A review of resident #2's uai dated 2-20-20 noted dressing assessed human help/supervision (HH/S), however, the ISP dated 2-20-20 noted "requires physical assistance with dressing, staff to assist with fine motor details of dressing". Resident's uai noted stairclimbing assessed need, mechanical help/human help/supervision, however, the ISP noted "mechanical assistance with stairclimbing, use of handrails". Mobility need assessed on uai noted mechanical help/human help/supervision, however, the ISP noted mechanical assistance, "use of walker/wheelchair". Resident #1's uai noted resident assessed to be disoriented some spheres, some of the time, however, the ISP did not address resident' s orientation need. 3. A review of resident #3's uai dated 12-23-29 noted dressing assessed mechanical help/human help/physical assistance, however, the ISP dated 1-23-20 noted physical assistance with dressing, staff assist. Stairclimbing need assessed mechanical help/human help/physical assistance, however, the ISP noted mechanical assistance with stairclimbing, "handrails". Resident's April 2020 medication administration record (mar) and physician's order noted "May self-administer, Ocu-soft lid scrub topical pads, medicated, both eyes, daily". The ISP uai and ISP noted medication assessed to be administered by staff. 4. A review of resident #4's uai dated 3-17-20 noted dressing assessed human help/supervision, however, the ISP dated 3-17-20 noted resident "requires supervision with dressing", staff snap bra. Resident assessed wandering and disoriented some spheres all the time, however, assessed needs not noted on the ISP. Resident has a physician's order to wear (left) knee brace when ambulating, however, the ISP did note walking need, nor mechanical device. 5. A review of resident #5's uai dated 1-21-20 toileting assessed mechanical help/ human help/supervision, however the ISP dated 1-20-20 noted mechanical assistance/ grabbars. Walking assessed on uai as mechanical assistance; however, the ISP noted mechanical assistance, "use walker when ambulating and standby assist". Stairclimbing assessed mechanical help/human help/physical assistance, however, the ISP noted resident requires supervision and mechanical assist to climb stairs, staff stand by and use of handrails. Mobility assessed mechanical help/ human help/ physical assistance, however, the ISP noted resident requires supervision with mobility, will have companion/supervision at all times when off the home.
Plan of Correction:	22 VAC 40-73-(6)-450-C. Based on record review and staff interview, the facility failed to ensure comprehensive assessments of UAI an ISP included all assessed need for the following: Resident #1, #2, #3, #4 and #5. This item was corrected day of inspection. Plan to ensure this does not happen again when status changes occur to resident's needs, ISP will be updated in conjunction with UAI which will ensure compliance is met. Manager of Assisted Living and Memory Support will audit each other's ISP and UAI to ensure compliance. At resident Individualized Service Plans the team will also discuss for accuracy of the UAI and ISP. Team members that complete the UAI and ISP will be enrolled in a refresher course to ensure complete understanding.
Standard #:	22VAC40-73-650-C
Description:	Based on record review and staff interview, the facility failed to ensure the physician's orders were reviewed and signed within 14 days. Evidence: 1. During the remote inspection (5-19-20), the request for all physician's orders for medications, treatments, on the April 2020 medication administration record (mar) for the sampled resident's were requested. A second request was made on 5-26-20. A review of the physician's orders submitted for residents #1, #2, #3, #4, and #5 submitted on 5-26-20 noted all physician's orders were signed and dated by the prescriber on 5-26-20 following the inspector's second request for signed physician's orders. 2. Resident #1's physician's orders submitted on 5-26-20 signed and dated 5-26-20 at 13:29. Resident #2's orders signed and dated 5-26-20 at 13:51. Resident #3's orders signed and dated 5-26-20 at 13:14. Resident #4's orders signed and date 5-26-20 at 14:30. Resident #5's orders signed and dated 5-26-20 at 13:36.
Plan of Correction:	22-VAC 40-73-(6)-650-C. Based on residents #1, #2, #3, #4, and #5 record review and staff interview, the facility failed to ensure the physician's orders were reviewed and signed within 14 days. Resident #1, #2, #3, #4 and #5 orders are signed. Plan moving forward is that Manager of Assisted Living and Memory Support will check their dashboards daily and will forward information to the Nurse Practioner to ensure all orders are dated and signed within 14 days as required by regulations. Weekly reports will be run to ensure all treatment plans are signed and dated for final checks and balance. .