VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Glebe
200 The Glebe Boulevard
Daleville, VA 24083
(540) 591-2100

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: May 15, 2020 and May 18, 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 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. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Technical Assistance:

The administrator and inspector had discussions regarding regulations 700-1, 680-K, and 450-D.

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 5/14/2020 and concluded on 5/18/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 45. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, new staff records were partially reviewed, health care oversight, fire inspection report, Health Department inspection report, Fire and Emergency drill logs, staff schedules, and the dietitian oversight report were reviewed, submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based on review of resident records, the facility failed to show what hospice services are provided to residents in individualized care plans (ISP). EVIDENCE: 1. The ISP for resident 1 shows this resident receives hospice services, but they are not specified on the ISP. 2. The ISP for resident 2 shows this resident receives hospice services, but they are not specified on the ISP.
Plan of Correction:	Plan of Correction: This Plan of Correction is our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state regulation. The ISP for resident 1 & 2 were corrected no later than 5/28/2020. The ISP?s were updated to meet the requirement s outlined in 22VAC40-73-450-D, ?when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. These services shall be included in the ISP?. The facility ISP specified hospice care would provide end of life support and meet the agreed upon wishes as outlined by the resident and family as a result of COVID-19 restrictions on visitation. The facility corrected and specified all other ISP needs hospice was providing during the service plan period. The facility will audit every resident currently/and moving forward under hospice services to ensure the ISP will meet the requirement as outlined in the regulation. The facility will ensure compliance through a quarterly record review of any resident receiving hospice services for the reminder of the licensing period. The facility will have a goal of 100% compliance. The facility QA committee will also monitor the quarterly audit report to ensure ongoing compliance.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to ensure that an order for oxygen was complete. EVIDENCE: 1. The oxygen order for resident 3 does not specify the source of the oxygen.
Plan of Correction:	The oxygen order for resident 3 specified; ?Oxygen 3L, by nasal canula; change and label oxygen tubing and humidified water on the 1 st Monday of every month?. The facility was sited because the order did not specify tank or concentrator as outlined in the regulation; 22VAC40-73-(6)-700-1. The facility has corrected resident (3)?s order to specify tank when out of the apartment and concentrator when in the apartment. The facility will audit every resident?s chart with O2 order to ensure they are written to meet the requirement as outlined in the regulation. The facility will have a goal of 100% compliance. The facility will ensure compliance through a quarterly audit to validate all aspects of the order as outlined in 22VAC40-73-(6)-700-1. The facility will do a quarterly audit of all O2 residents for the reminder of the licensing period. The facilities QA committee will also monitor the quarterly audit report to ensure ongoing compliance.