VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Lake Prince Woods
100 Anna Goode Way
Suffolk, VA 23434
(757) 923-5500

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Aug. 15, 2019 and Aug. 16, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

An unannounced renewal inspection was conducted by the Licensing Inspector from the Eastern Regional Office on 08-15-2018 from 8:25 AM to 4:10 PM and on 08-16-2019 from 8:30 AM to 2:19 PM. There were 40 residents in care at the time of the inspection. A tour of the facility was conducted and lunch and an activity were observed. Medications were observed for three residents. 8 residents and 4 staff records were reviewed, along with the criminal background checks and sworn disclosures for new hires since the previous renewal inspection. Interviews were conducted with residents and staff. First Aid kits for the facility and van were reviewed. Emergency preparedness regarding the fire and evacuation emergency drills were reviewed and discussed with the Maintenance Director. The following was discussed with the Administrator: TB screenings, ISPs/UAIs, medication administration, verbal orders, activity calendars,menus, and the health care oversight. The facility received the following violations "under" Personnel, Admission, Retention, and Discharge of Residents, Resident Care and Related Services, Emergency Preparedness, and Additional Requirements for Facilities that Care for Adults with Serious Cognitive Impairments. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview. Please complete the ?plan of correction? for each violation cited on the violation notice and return it to me within 10 calendar days from today, 09-29-2019.

Violations:

Standard #:	22VAC40-73-1120-B
Description:	Based on record review and interview, the facility failed to ensure there was at least 21 hours of scheduled activities available to the residents each week. Evidence: 1. On 08-16-2019, staff #1 provided a copy of the July and August 2019 activity calendars for ?The Cove? (Special Care Unit). The activity calendars documented ?Activities in lower case letters are led by a non-activity person and are at least 30 minutes in duration. Activities with a (+) are less than 30 minutes in duration (as tolerated).? Upon review of the scheduled activities, the facility did not have at least 21 hours of scheduled activities available to the residents during the following weeks: 07-07-2019 through 07-13-2019; 07-14-2019 through 07-20-2019; 07-21-2019 through 07-27-2019; 07-28-2019 through 08-03-2019; and 08-04-2019 through 08-10-2019. 2. During interview on 08-16-2019, staff #1 and staff #7 acknowledged the hours documented on the July and August 2019 activity calendars for ?The Cove? (Special Care Unit) did not reflect at least 21 hours of scheduled activities during the aforementioned weeks.
Plan of Correction:	The Activities Director will indicate on the calendar that all activities that are UPPERCASE are planned for one hour in duration. The AL Administrator and the Activities Director will meet monthly to review hours indicated on the current and up-coming calendars with the goal of 21 for each week. The working calendar posted on the unit will indicate total number of hours rendered for activities completed per week.
Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview, the facility failed to ensure each direct care staff maintained current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. On 08-15-2019, staff #3 was observed administering the morning medications to residents #1 and #2. 2. On 08-16-2019 during staff #3?s record review with staff #1 and staff #2, staff #3 was hired as a Registered Medication Aide on 05-28-2019. Staff #3 had a CPR certification on file via EMS Safety; however there was no documentation of a first aid certification on file from one of the approved providers. 2. During interview on 08-16-2019, staff #1 stated staff #3 did not have certification in first aid.
Plan of Correction:	The Human Resource Manager will audit and review all direct care staff for the approved first aide training offered by one of these entities: American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Staff #3 will be enrolled in the proper first aide training course. AL Director will maintain a copy of the first aide cards for monthly review and audit. AL Director will notify direct care staff prior to certifications expiring. Monthly
Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview, the facility failed to ensure the physical examination included the address and telephone number, the date of the physical examination, height, and any recommendations for medications. Evidence: 1. On 08-15-2019 and 08-16-2019, during resident record review with staff #1 and staff #2, the following physical examinations did not include the required information: a. Resident #2?s physical examination was signed by the physician on 05-20-2019; however, the date of the exam which is located on the top right corner of the first page of the exam was missing. Additionally, the physical examination did not include the residents? address, phone number, or height. b. Resident #3?s physical examination dated 10-07-2018 documented to ?see attached sheet? for the medication recommendation; however, a medication sheet was not attached to the exam. c. Resident #6?s physical examination dated 04-09-2019 documented to ?see attached list? for the medication recommendation; however, a medication list was not attached to the exam. 2. During interview on 08-15-2019 and 08-16-2019, staff #1 and staff #2 acknowledged the aforementioned items on resident #2, resident #3, and resident #6?s physical examinations were missing.
Plan of Correction:	The AL Administrator and AL Director will complete an internal audit of physical examinations to ensure all areas are dated and no missing documentation. When there is a physical examination with notes ?see attached? for medications, the attached paperwork will remain attached to the exam report. A copy of the medications may be made for order entry purposes. Prior to admission, the AL director will review all physical examinations for completeness. Exam date missing, resident?s address, phone number and height The AL Administrator will complete a follow-up review prior to paperwork being transferred to the resident?s record. Ongoing when completed
Standard #:	22VAC40-73-440-A
Description:	Based on record review and interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed annually for each resident. Evidence: 1. On 08-16-2019, during resident #7?s record review with staff #1 and staff #2, the most current UAI on file was dated 07-22-2018. Staff #1 and staff #2 were unable to locate and/or provide documentation of a completed annual UAI for resident #7. 2. During interview on 08-16-2019, staff #1 stated resident #7?s UAI dated 07-22-2018 was the most current UAI on file and acknowledged the facility did not complete the annual UAI for resident #7.
Plan of Correction:	The AL Director and The Clinical Coordinator reviewed and completed an updated assessment for resident #7. The AL Director and AL Administrator will complete an audit of all resident?s UAI to ensure annual compliance. A monitoring tool will be completed to indicate the month that the resident assessments are due. The AL Director will maintain list and check it monthly for upcoming reviews.
Standard #:	22VAC40-73-440-D
Description:	Based on record review and interview, the facility failed to ensure the Uniform Assessment Instrument (UAI) was completed as required by 22VAC30-110 for private pay individuals. Evidence: 1. On 08-16-2019, during resident #6?s record review with staff #1 and staff #2, the resident was admitted to the facility on 05-21-2019 and is private pay. The UAI on file did not document the date of assessment, social security number, current address, phone number, birth date, marital status, the level of assistance needed for medication administration, the residents behavior pattern and orientation, if a current psychiatric or psychological evaluation was needed, if the resident had a prohibitive condition, the level of care approved, or a signature from the assessor and administrator or designee. Staff #1 and staff #2 were not able to locate and/or provide documentation of a completed UAI on file for resident #6. 2. During interview on 08-16-2019, staff #1 and staff #2 stated the UAI in resident #6?s record was the most current UAI on file.
Plan of Correction:	The Clinical Coordinator and AL Director updated Resident #6 UAI. The missing documentation was entered and signed by administrative staff. Resident #6 UAI was placed in the resident?s record. The AL Director, LPN Clinical Coordinator along with other UAI certified personnel will complete the UAI assessments. Each UAI that is completed will be reviewed and verified for accuracy and completeness by the AL Administrator prior to filing in resident?s charts. Ongoing when completed
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview, the facility failed to ensure the Individualized Service Plan (ISP) was reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. Evidence: 1. On 08-15-2019, during resident #1?s record review with staff #1 and staff #2, a ?Fall Risk Assessment? form documented the resident was assessed by staff as being a high risk for falls on 07-12-2019, 07-15-2019, 07-21-2019, and 07-24-2019; however, the most current ISP dated 12-10-2018 was not updated to reflect the resident was a high risk for falls. Additionally, the current physicians orders dated 07-11-2019 documented the resident was on a mechanical soft diet; however, the ISP was not updated to reflect the resident?s mechanical soft diet. 2. On 08-16-2019, during resident #7?s record review with staff #1 and staff #2, the most current ISP on file was dated 07-12-2018. Staff #1 and staff #2 were unable to locate and/or provide documentation to verify the ISP was reviewed and updated at least once every 12 months. 3. During interview on 08-15-2019 and 08-16-2019, staff #1 and staff #2 acknowledged the facility did not review and update resident #1?s ISP regarding the resident being a high risk for falls and the change in diet. Staff #1 also stated resident #7?s aforementioned ISP was the most current ISP on file and acknowledged that the facility did not review and update the resident?s ISP every 12 months as required.
Plan of Correction:	The Clinical Coordinator updated Resident #1 fall risk status and diet on the ISP. The Coordinator reviewed and dated the ISP for resident #7. The AL Director and the Clinical Coordinator will evaluate all residents considered a fall risk to ensure appropriate fall risk interventions are in place and documented. All diets were audited for accuracy and updated as needed. The AL Director and AL Administrator will complete an audit of all the ISP?s to ensure annual compliance. A table will be completed to indicate the month that the resident assessments are due. The AL Director will maintain list and check it monthly for upcoming reviews.
Standard #:	22VAC40-73-490-A-2
Description:	Based on record review and interview, the facility failed to ensure the licensed health care professional, practicing within the scope of his profession, provided a health care oversight at least every three months, or more often if indicated, based on his professional judgment of the seriousness of a resident's needs or stability of a resident's condition. Evidence: 1. On 08-15-2019, during review of the facility?s health care oversight from August 2018 to August 2019 with staff #1 and staff #2, an oversight was conducted by an outside agency with a beginning date of 09-2018 and a completion date of 02-2019. This healthcare oversight was not provided every three months. 2. During interview, staff #2 stated the facility?s healthcare oversight is completed by an outside agency and acknowledged the healthcare oversight was not completed every three months during 09-2018 to 02-2019.
Plan of Correction:	The AL Administrator has an appointment scheduled to finalize 2019-2020 calendar for quarterly on-site visits. . The AL Administrator will ensure that healthcare oversite is completed every quarter.
Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview, the facility failed to ensure the physician's or other prescriber's oral orders are reviewed and signed by a physician or other prescriber within 14 days. Evidence: 1. On 08-15-2019, during resident record review with staff #1 and staff #2, the following verbal orders were not signed by the physician or other prescriber within 14 days: a. Resident #1 had a verbal order dated 04-24-2019 for PT [physical therapy] clarification which was not signed by the physician until 05-20-2019; a verbal order dated 06-05-2019 requesting to crush medications PRN [as needed] which was not signed by the physician until 07-11-2019; and a verbal order dated 06-13-2019 to discontinue PT services which was not signed by the physician as of 08-15-2019. b. Resident #2 had a verbal order dated 06-05-2019 requesting to crush medications PRN; however the order was not signed by the physician as of 08-15-2019. 2. During interview on 08-15-2019, staff #1 and staff #2 acknowledged resident #1 and resident #2?s aforementioned verbal orders were not signed by the physician or other prescriber within 14 days.
Plan of Correction:	The Clinical Coordinator will educate team members on protocol regarding telephone orders. Telephone orders or oral orders given will be signed by prescriber within 14 days. The Clinical Coordinator will review telephone/oral orders twice weekly and weekly by the AL Director to ensure compliance for 3 months. The Clinical Coordinator will conduct weekly checks to follow up with the prescriber?s outstanding telephone orders. Staff will document attempts to retrieve for appropriate prescriber?s signatures. Weekly for 3 months
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications are administered in accordance with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. According to the current Virginia Board of Nursing registered medication aide curriculum ?18VAC90-60-110. Standards of practice. A medication aide shall not: Administer by subcutaneous route, except for insulin medications, glucagon, or auto-injectable epinephrine.? 2. On 08-16-2019, during resident #7?s record review with staff #1 and staff #2, a physician?s order dated 06-27-2019 documented ?Tuberculin syringe 1 mL 27 x ?? (1vial) syringe- use 1 vial to administer Heparin injection every 12 hrs. Dx: Prophylatic DVT.? 3. On 08-16-2019, resident #7?s July 2019 Medication Administration Record (MAR) documented the Heparin 5,000 unit/mL injections were administered by Registered Medication Aides (RMA) on 07-03-2019 by staff #8, and on 07-08-2019 and 07-22-2019 by staff #3. 4. During interview on 08-16-2019, staff #2 stated staff #3 and staff #8 are RMA?s. Staff #1 and staff #2 acknowledged staff #3 and staff #8 were not qualified to administer the Heparin injections to resident #7.
Plan of Correction:	The AL Director and Clinical Coordinator will conduct Medication Administration Training with all Registered Medication Aides and Licensed Nurses pertaining to VA Standards of Practice for Registered Medication Aides, with focus on allowable practices of injections by a registered medication aide. Staff #3 and staff #8 received additional training on medication management practice and procedures. Residents that have subcutaneous injections will be reviewed by the AL Director monthly to ensure compliance. Ongoing monthly
Standard #:	22VAC40-73-680-E
Description:	Based on record review and interview, the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber are provided according to his instructions and documented. The documentation should be maintained in the resident's record. Evidence: 1. On 08-16-2019, during resident #3?s record review with staff #1 and staff #2, the resident had a physician?s order dated 07-11-2019 (original order dated 12-30-2018) documenting a treatment for ?Daily weights. Notify MD if patient gains 3 LB in a day or 5 LB or greater in a week. Monitor patient for increased edema or increased SOB on exertion.? The July 2019 Medication Administration Record documented the resident had a 3 LB weight gain in one day from 07-10-2019 (294.40 lbs) to 07-11-2019 (297.60 lbs). Staff #1 and staff #2 could not verify and/or provide documentation in the resident?s record of the physician being notified of resident #3?s weight gain from 07-10-2019 to 07-11-2019. 2. On 08-16-2019, during resident #2?s record review with staff #1 and staff #2, the staff wrote a verbal order to the nurse practitioner dated 06-07-2019 documenting ?Res is having some frequency upon urination. Urine is strong and resident complained of some burning upon urination. May we please have an order for UAC&S...? There was an order that was signed and dated on 06-07-2019 by the nurse practitioner to ?obtain UAC&S;? however, staff #1 and staff #2 could not locate and/or provide documentation in the resident?s record verifying the staff obtained a UAC&S for resident #2. 3. During interview on 08-16-2019, staff #1 stated the facility did not notify the physician or have documentation of the physician being notified of resident #3?s weight gain from 07-10-2019 to 07-11-2019. Staff #1 also stated the facility did not obtain a UAC&S for resident #2.
Plan of Correction:	The AL Director and Clinical Coordinator will review with the team members the importance of following the prescriber?s orders. All Prescriber?s orders will be reviewed by the AL Director, clinical coordinator, and/or designated person in charge daily. Orders for daily weights with parameters will be reviewed 3x week to ensure compliance and physician follow-up as appropriate by the AL Director or Clinical Coordinator. All labs ordered should be completed timely, if unable to collect or missed the prescriber will be notified. Nightly Chart reviews will be completed and follow up of incomplete orders will be reviewed and corrective action taken by the clinical coordinator to ensure compliance. Daily
Standard #:	22VAC40-73-680-H
Description:	Based on record review and interview, the facility failed to document on a Medication Administration Record (MAR) all medications administered to residents at the time the medication is administered. Evidence: 1. On 08-15-2019, during the morning medication pass observation at approximately 9:08 AM, staff #3 was observed administering the following scheduled 9:00 AM medications to resident #2: Linzess 145 mcg, Miralax 17gm, Multivitamin, Prilosec 20mg, Risperdal .25mg, and Celebrex 100mg 2. On 08-15-2019, during resident #2?s record review with staff #1 and staff #2, the current physician?s orders on file dated 08-05-2019 documented ?Zinc oxide 20% topical ointment? Apply small amount to perinea area morning and night?? The scheduled administration times on the orders were 9:00 and 21:00. This ointment was not observed during the morning medication pass observation with staff #3. 3. On 08-16-2019, upon review of resident #2?s August 2019 MAR with staff #2 and staff #6, the MAR was initialed by staff #3 at 9:08 AM documenting the zinc oxide ointment was administered to resident #2 at the same time the other scheduled 9:00 AM medications were administered. 4. During interview on 08-16-2019, staff #3 was informed by the Licensing Inspector that the zinc oxide ointment was not observed as being administered to resident #2 during the 9:00 AM medication pass observation on 08-15-2019 at approximately 9:08 AM. Staff #3 stated? the ointment was administered to the resident when the resident woke up;? however, she ?forgot to sign the MAR.? Staff #3 acknowledged the zinc oxide ointment was not documented on the August 2019 MAR at the time the ointment was administered.
Plan of Correction:	The AL Director and The Clinical Coordinator will conduct med pass observations on team members eligible to pass medications. Education on medication administration will be provided to the identified team members. Staff #3 will receive one on one education regarding satisfactory expectation regarding each medication administration episode. The AL Director and/or Clinical coordinator will monitor medication administration weekly.
Standard #:	22VAC40-73-970-E
Description:	Based on record review and interview, the facility failed to ensure a record of the required fire and emergency evacuation drills included the number of residents who participated in the drill. Evidence: 1. On 08-16-2019, during review of the facility?s fire and emergency evacuation drills with staff #5, the drills conducted on 04-17-2019 (3rd shift), 05-28-2019 (2nd shift), and 06-26-2019 (1st shift) did not include the number of residents who participated in the drill. 2. During interview on 08-16-2019, staff #5 acknowledged the aforementioned fire and emergency evacuation drills did not include the number of residents who participated in the drill.
Plan of Correction:	The Director of Plant Operations will continue to conduct fire drills per facility standard. The AL Administrator will review the fire drill documentation after each drill to ensure that the required number of residents participating is documented.
Standard #:	22VAC40-73-980-B
Description:	Based on observation and interview, the facility failed to ensure in facilities that have a motor vehicle that is used for a field trip and is used to transport residents, there should be a first aid kit on the vehicle that includes the required items. Items with expiration dates must not have dates that have already passed. Evidence: 1. On 08-15-2019, during review of the first aid kit located on the facility?s van with staff #4, a bottle of antiseptic ointment was observed with an expiration date of 01-2018 and a bottle hand cleaner was observed with an expiration date of 12-2016. 2. During interview, staff #1 and staff #4 acknowledged the first aid kit located on the facility?s van contained expired antiseptic ointment and hand cleaner.
Plan of Correction:	The AL Administrator and Resident Services Coordinator reviewed all first aid kits located on the transport vehicles. The first aid kits were updated and will be checked weekly by the Resident Services Coordinator for expired items. She will replace as needed. Monitoring will continue weekly for 3 months. The AL Administrator will review the actions of the RSC and spot check to ensure compliance with regulation. (Expiration and missing items) The Resident Services Coordinator will continue to check the first aid kits monthly for 4 months. The Director of Resident Services will verify monthly that all items are available and are not expired.