VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Second Chance
524 Pisgah Church Road
Rice, VA 23966
(434) 392-9276

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 5, 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 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.

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 05/05/2021 and concluded on 05/11/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 9. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, recent health care oversight, most recent health department and fire inspections, sworn disclosure and criminal record check for employees hired since the last mandated inspection, dates of the past 3 fire drills, recent six month practice of plan for resident emergencies, recent pharmacy review and recent dietitian review of special diet submitted by the facility to ensure documentation was complete. 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 #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure that the Uniform Assessment Instrument (UAI) was completed as required. EVIDENCE: 1. The Individualized Service Plan (ISP) for resident 1, dated 01/21/2021, showed ?continues to occasionally have wetting accidents due to bladder incontinence?. The public pay UAI for resident 1, dated 04/27/2020 does not indicate that the resident has bladder incontinence. Interview with staff 2 revealed that the ISP is correct, and the UAI assessment is incorrect. 2. The ISP for resident 2, dated 01/21/2021, showed ?(Resident 2) requires supervision due to his Diagnosis of Autism, Psychosis, and history of elopement and attempts.? The public pay UAI for resident 2, dated 08/28/2020, showed resident 2 has an appropriate behavior pattern. Interview with staff 2 revealed that the ISP is correct, and the UAI assessment is incorrect.
Plan of Correction:	The Administrator and ALF Coordinator reviewed 22VAC40-73-(6)-440-A, the noted resident?s ISP, and UAI for needed changes per standard. The Administrator and Coordinator also reviewed all Second Chance Resident?s ISPs and UAIs to identify other potential areas wherein the UAI may have not included all information or support needs noted on the ISP. The Administrator and Coordinator contacted Crossroads CSB MH Case-manager Supervisor-Barbara Vanderool on 05/10/2021 via telephone to request corrections/revisions to be made to the noted UAIs. Upon receipt of the revised UAIs, the Administrator will review and file in the resident?s records. Upon receipt of any UAIs in the future, the Administrator and ALF Coordinator will review and compare to the current ISP to ensure both include all support needs are required per standard.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, the facility failed to ensure that the comprehensive individualized service plan (ISP) included all required components. EVIDENCE: 1. The ISPs for resident 1 and 2, dated 01/21/2021, stated that medications are administered by direct care staff. An interview with staff 2 indicated that staff who are registered medication aides (RMAs) are responsible for administering medications to both residents 1 and 2. 2. The ISP for resident 1, dated 01/21/2021, stated that the resident requires qualified mental health professional (QMHP) services due to his diagnosis of organic mood disorder, secondary to traumatic brain injury. The ISP for resident 2, dated 01/21/2021, stated that the resident requires mental health services from a QMHP due to his diagnosis of psychosis. The ISPs for both resident 1 and 2 also stated that mental health services would be provided by direct care staff. An interview with staff 2 indicated that the mental health services are provided by mental health caseworkers and not direct care staff for residents 1 and 2.
Plan of Correction:	The Administrator and ALF Coordinator reviewed 22VAC40-73-(6)-450-C, the noted ISPs, and all current ISPs for each resident to identify corrections needed. All ISP?s will be revised to include the correct support staff and their titles for each area needed in the ISP. This will include clarification of all facility roles, titles, and support instructions to ensure the ISP includes correct indications of support provisions by the appropriate employee or service provider and what steps should be taken by staff to do so appropriately.
Standard #:	22VAC40-73-550-F
Description:	Based on resident record review, the facility failed to ensure that the rights and responsibilities of residents contained the name and telephone number of the appropriate regional licensing supervisor of the department. EVIDENCE: 1. The Rights and Responsibilities of Residents of Assisted Living Facilities form for residents 1 and 2, dated 01/04/2021, indicated that the regional licensing administrator is Jennifer Stokes, with telephone number 540-589-5216; however, the correct regional licensing administrator is Nancy Hunter, with telephone number 540-309-2796.
Plan of Correction:	The Administrator reviewed the current Rights and Responsibilities form being used in the Facility to identify other potential errors. The current form was updated to reflect the appropriate licensing personnel as noted in the violation summary immediately. The Administrator and ALF Coordinator will meet with each resident to ensure they review and sign the updated Rights and Responsibilities form. The Administrator will ensure that any future changes to regional licensing supervisors be updated on all applicable forms within 24 hours of notice.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, the facility failed to ensure that physicians or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements included the diagnosis, conditions or specific indications for administering each drug. EVIDENCE: 1. Current physician?s orders for resident 1 did not include the diagnosis, conditions or specific indications for administering the following medications: Quetiapine 400 mg tab, Haloperidol 5 mg tab, Amiloride HCL 5 mg oral tab and Tamsulosin 0.4 mg capsule.
Plan of Correction:	The Administrator and ALF Coordinator reviewed 22VAC40-73-(6)-650-B, the noted violations, and referenced resident?s current physician orders. The Administrator contacted the resident?s physician and requested new orders for the noted medications to include all needed information as noted in the violation. (05/06/2021 Dr. E Crossroads CSB via telephone) The Administrator will ensure the updated orders are filed in the resident record and MAR upon receipt. The Administrator and ALF Coordinator reviewed the physician orders on hand for each resident to ensure all orders include all required elements and information per the noted standard. All future physician orders received will be reviewed by the Administrator, ALF Coordinator, or Healthcare Oversight Nurse to ensure all information is present prior to placing in the resident?s record or MAR. The Administrator and ALF Coordinator will conduct monthly audits of all physician orders and MAR Records to prevent future violations. The Health Care Oversight Nurse will review the current Medication Management Plan with all RMAs during their annual medication refresher training being held on 05/17/2021 with each RMA.
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review, the facility failed to ensure that the medication administration records (MARs) contained all required elements. EVIDENCE: 1. The May 2021 MAR for resident 1 did not contain the diagnosis, condition, or specific indications for administering the following drugs or supplements: Atorvastatin 10 MG and Famotidine 20 MG. 2. The May 2021 MAR for resident 2 did not contain the diagnosis, condition, or specific indications for administering the following drugs or supplements: Januvia 100 MG, Atorvastatin 20 MG, Lisinopril 5 MG, Glipizide 5 MG, Buspirone HCL 10 MG, Metformin HCL 1,000 MG and Lorazepam 1 MG.
Plan of Correction:	The Administrator and ALF Coordinator reviewed 22VAC40-73-(6)-680-I, the noted violations, and referenced resident?s current MARS. The Administrator contacted the facility?s pharmacy regarding the MARS provided and missing information. (05/06/2021 Tana/Bremo LTC via telephone) The Administrator contacted the Healthcare Oversight Nurse, Mrs. Ownby, to inform her of the noted violation and have the MARS corrected immediately. The Administrator and ALF Coordinator reviewed the MARS for each resident to ensure that each medication listed on the MAR included all required information as noted in the violation and required per standard. All MARS received in the future from the pharmacy will be reviewed by the Administrator, ALF Coordinator, or Healthcare Oversight Nurse to ensure all information is present prior to placing in the resident?s record or MAR Record for use. The Administrator and ALF Coordinator will conduct monthly audits of all physician orders and MAR Records to prevent future violations. The Health Care Oversight Nurse will review the current Medication Management Plan with all RMAs during their annual medication refresher training being held on 05/17/2021 with each RMA.
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review, the facility failed to ensure that a sworn statement or affirmation (SD) was completed for all applicants for employment. EVIDENCE: 1. Staff 1, date of hire 08/05/2020, completed the SD after employment on 08/12/2020.
Plan of Correction:	The Administrator and Human Resource Coordinator reviewed 22VAC40-90-(BC2)-30-B and the current forms being utilized with all applicable job posting/hiring systems, such as INDEED, that were put in place during the COVID-19 pandemic. The SD form has been added to all initial application processes and forms to ensure applicants complete upon application as required by noted standard. The administrator and Human Resource Coordinator will review all methods of application resources such as INDEED monthly to ensure the SD form is available to all applicants and included in all other application packets that may be used.