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. 21, 2022 and Nov. 22, 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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 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:

1. Ensure all information is completed on all forms and if the information is not applicable, recommended writing N/A rather than leaving the section blank. Ensure all forms are carefully reviewed prior to filing. 2. All medications that are ordered must be on site, in the medication cart/refrigerator and labeled with a resident?s name. Stock medications are not allowed in assisted living. 3. Recommended all direct care staff complete the number of training hours required for the secured unit, even it they do not work on the unit, so if needed, they could be pulled to work on the secured unit as well. 4. Reviewed the updated orientation form being used for volunteers and made one recommendation for change. 5. Recommended adding the annual review of the sex offender registry information onto the residents? rights signature form to eliminate having to complete two separate forms. 6. Once the rest of the elevator inspections have been completed, notify this inspector. 7. Ensure a column for corrective actions taken is added to the fire drill model form. Note: There were no problems documented on the fire drill forms reviewed. 8. Recommended the allergies and the allergic reactions be separated into two different sections on the initial physical form.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 11/21/2022 from approximately 7:40 am to 6:15 pm and 11/22/2022 from approximately 7:00 am to 5:20 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 32 (16 assisted living, 16 secured unit) The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 + 2 additional selected sections Number of staff records reviewed: 3 + 4 additional selected sections Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 4 Observations by licensing inspector: Activities, meals, staffing, medication administration observations, medication carts, staff to resident interactions. Additional Comments/Discussion: Observed both the assisted living and secured units and reviewed records on both units. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-220-A
Description:	Based upon documentation and an interview, the facility failed to ensure all required documentation was on file and training was completed for the one private sitter/companion who was providing services in the facility. Evidence: 1. The record for collateral 1 was reviewed and did not include the following information: The services to be provided to resident 5 by the companion were not obtained in writing; the services provided by the companion were not listed on the individualized service plan (ISP); orientation and training regarding the facility?s policies and procedures related to the duties of the companion were not completed; and documentation of the services provided were not being documented. 2. On 11/21/2022, the LI interviewed the administrator who stated he reviewed the standards for private sitters/companions, and they did not have all of the required information listed above completed and on file.
Plan of Correction:	? The private companion has been contacted and will complete all required documentation and training before the start of their next shift. ? A packet for onboarding new private companions will be developed based on the information required in standard ? 220.A. When a new companion is retained by a resident, the Director of Nursing will ensure all clinical paperwork is in place. This information will then be passed on to the Director of Human Resources for orientation and final filing of the documents. All of this will take place before the private companions first day of service at the community. The Director of Human Resources will ensure an up-to-date personnel file is kept on all private companions. ? The administrator of record will conduct an audit of the private companion files on a quarterly basis to ensure all requirements addressed in standard 220.A are completed and on file and compliance is maintained.
Standard #:	22VAC40-73-290-A
Description:	Based upon documentation and an interview, the facility failed to ensure the written staff work schedule included who was in charge at any given time. Evidence: 1. The written staff schedule for 11/6/2022 through 11/21/2022 did not indicate the person who was in charge at any given time. 2. On 11/21/2022, the LI interviewed the director of nursing (DON) who stated the staff in charge was not indicated on the schedule but all staff knew the nurse or medication aide on duty was always the person in charge.
Plan of Correction:	? The written staff work schedule was corrected during the monitoring inspection. It is now clearly labeled with the staff person in charge on each shift. ? The scheduler will be responsible for ensuring the person in charge is clearly labeled on the printed staff schedules each day for all three shifts. ? The director of nursing will visually inspect the schedule bi-weekly (each time the schedule is posted) to ensure compliance with standard 290.A.
Standard #:	22VAC40-73-680-M
Description:	Based upon observations, documentation and an interview, the facility failed to ensure all as- needed (PRN) medications were available for one of four residents. Evidence: 1. Resident 4 had physician?s orders signed 10/24/2022 for Acetaminophen and Rolaids Advanced Chewable Tablet. 2. On 11/22/2022, the LI and staff 2 conducted a medication cart audit and the Acetaminophen and Rolaids for resident 4 were not in the cart. 3. On 11/22/2022, the LI interviewed staff 2 and 10 and both stated the medications were not in the cart or available.
Plan of Correction:	? The medications in question were obtained on the date of the monitoring inspection; they were properly labeled and stored for each resident. ? Moving forward, the attending physician will assess and discontinue medications that have not been used in the last 30 days. The pharmacy consultant will perform monthly audits to ensure all physician ordered medication is available and properly labeled in the medication carts. The pharmacy consult will then report findings to the director of nursing. ? The director of nursing will address any issues found within the monthly audits to ensure compliance with standard ? 680.M.
Standard #:	22VAC40-73-970-A
Description:	Based upon documentation and an interview, the facility failed to ensure fire drills were held each shift in each quarter. Evidence: 1. The fire drill forms indicated the last fire drill held on the 10:00 pm to 6:30 am shift was 6/30/2022. 2. On 11/21/2022, the licensing inspector (LI) interviewed staff 9 who stated he got mixed up on the shifts and put down third shift for a drill that was actually held on the second shift, which made his schedule off for the quarter.
Plan of Correction:	? Other than this instance, fire drills were conducted in accordance with standard 970.A. ? The director of plant operations will ensure all fire drills are conducted based upon the details outlined in standard - 970.A. He will sign off on the completion of the reports after each fire drill. ? The administrator of record will conduct a monthly audit to ensure compliance with standard 970.A