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: Oct. 18, 2021 , Oct. 19, 2021 , Oct. 20, 2021 and Oct. 21, 2021

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 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 discussed the following with the administrator and director of health services: 1. How to document on the uniform assessment instrument when a resident only self-administers a portion of his/her medications. Check "administered by lay person" and out to the side write the name of the self-administered medication/treatment and the date of the signed order to self-administer/keep at bedside. This same information should also be stated on the individualized service plan. 2. The orientation form must be signed by the resident, even if cognitively impaired, as the standard does not give an exception. The family member may also sign the form but not in place of the resident. If the resident gets anxious or refuses, document that information on the form. 3.The model form for staff orientation must be signed by the staff being trained rather than the trainer (NOTE: The trainer was also initialing and dating each training section blank appropriately.) 4. Be more specific on the individualized service plan as to the specific tasks provided by facility staff/agency staff/contract staff (regarding activities of daily living, wound care, hospice, etc.). 5. Recommended adding a "corrective actions taken" column to the model fire drill form (NOTE: There were no problems noted on any of the fire drill forms reviewed). 6. Although administrator stated all residents were capable of using the call bell system, reviewed standard 930.D.

Comments:

A renewal inspection was initiated on 10/18/2021 and concluded on 10/21/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 29. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed three resident records, three staff records, selected sections of one additional resident and five staff records, activities calendar, menu, staff schedules, fire drills, health care oversight, dietary reviews, September and October medication administration records, physicians' orders and other information submitted by the facility to ensure documentation was complete. The inspector conducted a virtual inspection on 10/21/2021. An exit interview was conducted with the administrator on the date of the virtual inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1110-B
Description:	Based upon documentation and interviews, the facility failed to ensure the six month review for continued placement in a secured unit was completed for one of three resident records reviewed. Evidence: 1. Resident 2 was admitted to the secured unit 12/1/2020; however, the review for continued placement was not on file. 2. On 10/20/2021, the LI interviewed the DHS and UM and both stated the review for continued placement in the secured unit had not been completed for resident 2.
Plan of Correction:	1. Resident #2's review for continued placement in a secured unit was completed. An audit has been completed for all other residents on the secured unit for completion. 2. UM/DHS/director of social services will all be in-serviced on the requirement of continued placement in a secured unit. The UM/designee will keep a log of when residents are due. 3. The ED/DHS will audit resident charts monthly for timely completion of the continued placement in a secured unit form. 4. The results of these audits will be reported and reviewed at our QQA meetings for one year.
Standard #:	22VAC40-73-250-D
Description:	Based upon documentation and an interview, the facility failed to ensure two of four staff records reviewed had a tuberculin (TB) skin test/assessment completed prior to the first day of work at the facility. Evidence: 1. Staff 2 (rehired 9/2/2021) had a TB skin test dated as completed on 10/19/2021. 2. Staff 3 (hired 6/23/2021) had a TB skin test dated as completed on 6/26/2021. 3. On 10/20/2021, the LI interviewed the human resources director (HRD) who stated these were the completion dates of the TB skin tests.
Plan of Correction:	1. All new hires will have their TB skin test/assessment completed prior to the first day of work at the facility. 2. TB skin test/assessments will be completed on day of pre-employment screening for all potential new hires. The human resource director (HRD), as well as all department heads, will be in-serviced on this protocol. 3. The HRD will monitor that all new hires will have completed their TB assessments by day of orientation. This audit will also be signed off by the executive director (ED) prior to day of orientation. 4. The results of these audits will be reported and reviewed at our QQA meetings for one year.
Standard #:	22VAC40-73-260-A
Description:	Based upon documentation and an interview, the facility failed to ensure one of three staff completed first aid training within 60 days of employment. Evidence: 1. Staff 3 (hired 6/23/2021) did not have certification in first aid training. 2. On 10/20/2021, the LI interviewed the HRD who stated staff 3 had not completed first aid training as she missed the class due to an emergency.
Plan of Correction:	1. Staff #3 completed her first aid training on 11/1/21. An audit has been completed on all direct care staff for a completion of first aid training. 2. The HRD, as well as all department heads, will be in-serviced on the requirement for first aid training of direct care staff. The HRD will schedule monthly first aid trainings. 3. The HRD will keep a log of new hires and when training is due. The HRD will also do monthly audits of direct care staff of when their trainings are due and the ED will sign off on these audits. 4. The results of these audits will be reported and reviewed at our QQA meetings for one year.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and interviews, the facility failed to ensure one medication for one of three resident records reviewed was administered according to the physician's order. Evidence: 1. Resident 1 had a physician's order (signed 9/7/2021) for, "Quetiapine 25 mg tablet take one table by mouth every 8 hours." 2. The October electronic medication administration record (EMAR) was blank for Quetiapine on the following dates: 10/6/2021, 10/8/2021 and 10/14/2021 at 6:00 am and 10:00 pm; 10/9/2021 at 10:00 pm; 10/10/2021 through 10/13/2021 at 6:00 am. 3. On 10/21/2021, the licensing inspector (LI) interviewed the director of health services (DHS) and unit manager (UM) and both stated a glitch was discovered in the system during an audit when this issue was found. Both stated the medication was not showing up on the EMAR at various times and so staff did not see the medication and as a result it was not given nor initialed for the times listed.
Plan of Correction:	1. Resident #1's Quetiapine was discontinued on 10/15/21. All residents will have a medication audit completed. 2. All nurses and med techs will be in-serviced on the EMAR. The UM/DHS will review the EMARs on all residents five (5) days a week for any omissions. 3. The DHS/designee will do a weekly audit of the EMAR for three months and then monthly thereafter. 4. The results of these audits will be reported and discussed at the Quarterly Quality Assurance (QQA) meetings for one year.