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: Nov. 20, 2020 , Nov. 23, 2020 , Nov. 24, 2020 and Nov. 25, 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 63.2 General Provisions. 63.2 Protection of adults and reporting. 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 in and discussed the following areas: 1) Leniency was issued by the department on first aid training; however, ensure staff B completes the training as required by the leniency document. 2) Follow up telephone reviews of the individualized service plans with family members with an email and signed document by the family member or resident (only resident D's was not signed). 3) With an open med pass, when an order specifies a time (such as every 12 hours) then the time must be specific on the medication administration record - writing morning and evening is not sufficient) - had one medication for resident C like this). 4) When residents self-administer only a portion of their medications, check "administer by lay person" and out to the side state "per physician's orders dated ____ the resident may self-administer," then list the medications that may be self-administered. 5) Review all paperwork prior to filing to ensure all information is accurate and complete. The fire drill form had one drill that did not include the time to complete the drill. 6) Recommended rather than leaving a section blank, if it does not apply, indicate such by writing "N/A."

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 monitoring inspection was initiated on 11/20/20 and concluded on 11/25/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 23 (14 on assisted living and nine on the secured unit). The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident, one discharge, one volunteer, two contract staff and three staff records. Selected sections of three additional resident and four additional staff records were also reviewed. The inspector also reviewed fire drill log sheets, activities calendars, menu, staff schedules, dietary/medication/health care oversights, required postings, resident council meeting minutes and staff rounds log sheets. A virtual tour of both the assisted living and secured units and other various areas of the facility was also conducted. Information gathered during the inspection determined non-compliances in the areas of postings, uniform assessment instruments and individualized service plans, and violations were documented on the violation notice issued to the facility.

Violations:

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 first aid (FA) and cardiopulmonary resuscitation (CPR) certifications was kept up to date. Evidence: 1) During the virtual inspection on 11/24/20, the licensing inspector (LI) observed the posted FA/CPR list and it was dated as 2019. 2) On 11/24/20, the LI interviewed the executive director (ED) who stated the list was not current and had not been updated since 2019.
Plan of Correction:	1) A list of staff with current FA and CPR certifications is posted at the nursing stations. 2) The human resource director (HRD) has been in-serviced on keeping the list current and posting at each nursing station. 3) The HRD/clinical coordinator (CC) will monitor monthly to ensure the posting is current. 4) The results of the monitoring audit will be reported and reviewed at our Quarterly Quality Assurance (QQA) meetings for one year.
Standard #:	22VAC40-73-440-D
Description:	Based upon documentation, the facility failed to ensure three of the four uniform assessment instruments (UAIs) reviewed were completed as required. Evidence: 1) The UAIs for residents B (completed 12/30/19), C (completed 1/30/20 and 10/1/20) and D (completed 10/9/20) had disorientation checked; however, none of the spheres affected were indicated. 2) The UAIs for residents C and D were signed by the staff who completed the UAIs; however, the ED nor his designee had signed them.
Plan of Correction:	1) The UAIs moving forward for residents B, C and D will have orientation spheres affected noted where appropriate. Also, the UAIs moving forward for residents C and D will be signed by the ED/designee. 2) UAIs will be completed to its entirety with administrator/designee signature. The CC, social worker (SW), director of health services (DHS), and ED have been in-serviced on UAI completion and signatures required. 3) The CC/SW will be responsible for completing the UAI to its entirety and getting signatures. 4) The results of this monitoring audit will be reported and reviewed at our QQA meetings for one year.
Standard #:	22VAC40-73-450-C
Description:	Based upon documentation, the facility failed to ensure all needs were included on two of the four individualized service plans (ISPs) reviewed. Evidence: 1) The ISP for resident C (completed 10/8/20) did not include cups with lids and supervision with walking (as assessed on the UAI completed 10/1/20). 2) The ISP for resident D (completed 10/15/20) did not include the specific mechanical help needed for bathing and dressing (as assessed on the UAI completed 10/9/20).
Plan of Correction:	1) The ISP for resident C now includes cups with lids and supervision with walking. The ISP for resident D now includes the specific mechanical help needed for bathing and dressing. 2) Other ISPs have been audited to ensure resident needs are included with corrections added where necessary. The CC has been in-serviced on the importance of including resident needs in the ISPs. 3) The CC will be responsible for completing the ISPs per the standards and will be monitored by the DHS. 4) The results of this monitoring audit will be reported and reviewed at our QQA meetings for one year.