VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Summit Square
501 Oak Avenue
Waynesboro, VA 22980
(540) 941-3100

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Dec. 2, 2019 and Dec. 3, 2019

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 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

Technical Assistance:

Answered questions and made recommendations on the following: 1) Use the same model orientation form for the administrator as used for all other staff. 2) Answered questions regarding the date needs are identified on the individualized service plans as related to updated and annual reviews. 3) Recommended the emergency food and water agreements include the specific amounts of each to be delivered in an emergency. 4) May place a statement at the bottom of the activities calendar to indicate the minimum length of each activity rather than putting the time frame next to each activity. Also recommended the activities calendar be posted next to the menu, even though it was posted on the nursing office door. 5) When an independent living resident volunteers, ensure a copy of their emergency contact information is also placed in their volunteer file. 6) Reviewed and answered questions on standard 830.E and recommended a column titled "corrective actions taken" be added to the model form. (Note: There were no problems noted in the minutes reviewed). 7) Recommended storage cases, as well as glucometers, be labeled with the residents' names. (Note: One or both were labeled for all residents). 8) Recommended residents sign that they received a copy of their individualized service plans. 9) Clarify on the resident agreement the option for meal room service as it currently states only when there is a medical condition.

Comments:

An unannounced monitoring inspection was conducted on 12/2/19 from approximately 7:50 am to 4:30 pm and 12/3/19 from approximately 7:20 am to 7:00 pm. A tour was immediately conducted of the interior and exterior of the facility. There were 16 residents in care and one nurse and one certified nurses aide on duty. The facility was clean and free from any foul odors. All of the required postings were in place. The posted menu and activity calendar accurately reflected this inspector's observations and the special diets observed were served according to the physicians' orders, with the residents' choices being honored as well. Medication administration observations were completed for two residents with one nurse. The medication administration records, physicians' orders and medications for both residents were reviewed. Individual interviews were conducted with residents and staff. There were no family members available for interviews. Five residents, one discharge, two volunteers and four staff records were reviewed. Additional sections of five resident and six staff records were also reviewed. The areas of noncompliance included individualized service plans, dietary oversights and first aid kits. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-450-A
Description:	Based upon documentation and an interview, the facility failed to ensure three of the six individualized service plans (ISPs) reviewed were completed within the required time frame. Evidence: 1) The ISP for resident A (admitted 9/28/18) was completed on 9/30/18, resident B (admitted 6/12/18) was completed on 6/13/18) and resident E (admitted 12/18/18) was completed on 12/21/18. 2) On 12/3/19, the licensing inspector (LI) interviewed the assisted living unit manager (ALUM) who stated the preliminary plans of care were not completed within seven days prior to admission nor were the comprehensive ISPs completed on the day of admission..
Plan of Correction:	1) A chart audit will be completed on residents to assure all ISP dates are in compliance. A Quality Assurance Action Plan (QAAP) will be completed for those found to be out of compliance. 2) All ISPs will be completed within seven days prior to admission or a comprehensive plan will be completed on the day of admission. The ALUM and clinical coordinator (CC) will be educated regarding this standard. 3) The ALUM and/or CC will be responsible for completing the ISPs per the standard and will be monitored by the director of health services (DHS). 4) A QAAP has been developed to help monitor the protocol and will be reviewed for compliance at our quarterly quality assurance (QQA) meetings for one year.
Standard #:	22VAC40-73-620-B
Description:	Based upon documentation, the facility failed to ensure the dietary oversight included all of the requirements. Evidence: The dietary oversights completed since the last inspection did not certify that the requirements of the standard were met.
Plan of Correction:	1) The ALUM and the CC will audit resident charts for dietary oversight. The DHS and executive director (ED) will meet with the dietician to amend any reviews that do not meet compliance. 2) The dietician will be educated on the dietary oversight standard by the DHS and ED. A form will be implemented for the dietician to use to meet this standard. 3) The dietician will submit her oversights to the ED/designee to ensure compliance. 4) A QAAP has been developed to help monitor this protocol and will be reviewed for compliance at our QQA meetings for one year.
Standard #:	22VAC40-73-980-C
Description:	Based upon observations and documentation, the facility failed to ensure the vehicle first aid kits had items that were not past their expiration dates. Evidence: On 12/2/19, the LI checked the first aid kits in the vans and observed both kits contained antiseptic ointment that expired July 2019.
Plan of Correction:	1) Items that had expired were removed and replaced with antiseptic ointment with current expiration dates for the first aid kits identified. 2) The first aid kits in all the resident transportation vehicles have been audited for expired items. Any expired items were removed and replaced with items with expiration dates that were still current. 3) The life enrichment director (LED) will educate her staff on monitoring for expired items in the first aid kits. The LED will monitor monthly to confirm that items in the first aid kits are in compliance. 4) A QAAP has been developed to help monitor this protocol and will be reviewed for compliance at the QQA meetings for one year.