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: Dec. 8, 2020 and Dec. 15, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Technical Assistance:

The LI explained a training deadline to a staff person responsible for some training.

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 12/9/2020 and concluded on 12/16/2020. A complaint was received by the department regarding allegations in the areas of personnel, resident care and related services, and additional requirements for facilities that care for adults with serious cognitive impairments. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the monitoring inspection but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-440-A
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to update the uniform assessment instrument (UAI) when there was a significant change in a resident's condition. EVIDENCED: 1. The UAI for resident 3 dated 10/7/2020 showed this resident shows a behavior pattern of Wandering/Passive - Weekly or more. The nurses notes showed this resident exhibited Abusive/Aggressive/Disruptive behavior, Weekly or more. The notes detail incidents of such behavior on 10/29/2020, 11/1, 4, 5, 6, and 7/2020. The UAI for resident 3 also shows this resident is continent of bowel and bladder. Nurses notes dated 10/30/2020, 11/1, 4, and 5/2020 indicate the resident is not continent of bowel and bladder.
Plan of Correction:	The facility continues to review and updated resident UAI and ISP as conditions change related to baseline behavior. Based on the violation notice 22VAC-73-(6)-440-A Complaint related, the facility noted there was inconsistency in the resident 3, behavior between 10/29-11/7. The resident had been admitted directly into the facilities MC neighborhood with ongoing adjustment to daily routine, ADL assistance, and medication management. The facility was working in conjunction with the family and the medical director to determine the baseline behavior in these first two week of admission. Due to the unknown nature and the inconsistency of behavior the facility documented the change in the medical record and nursing notes. The UAI was maintained during the initial admission period in order for the facility personnel to accurately understand what the residents baseline behavioral pattern would be. The facility feels it maintained nursing oversight and accurate record of fluctuating behavior on a daily basis to ensure the residents was supported in their daily living needs. The facility will continue to update resident UAI in relation to 22VAC40-73-(6)-440-A The facility would like to request a desk review and conference to further evaluate the violation notice as issued .