VIRGINIA DEPARTMENT OF SOCIAL SERVICES

St. Charles Lwanga House G
2208 Jolly Pond Road
Williamsburg, VA 23188
(757) 345-2388

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: June 1, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 renewal inspection was initiated on 513-20; 5-15-20; 5-18-20 and concluded on 5-19-20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 5. The inspector e-mailed the administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, staff schedule, fire inspection, health department inspection, fire and emergency drills, oversight b dietitian/nutritionist and new hire since last renewal inspection ( date of hire, sworn statement/affirmation and criminal history record report. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on record review and staff interview, the facility failed to ensure it reported the licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health safety, or welfare of two of two residents. Evidence: 1. On 5-15-20 review of the remote renewal inspection documents, resident #2's physician's order dated 9-24-19 indicated resident temporary detained at a local mental facility. Resident dates at facility were 9-12-19 thru 9-16-19, auditory hallucination. 2. Staff #1 acknowledged residents' incident was not reported to licensing office.
Plan of Correction:	Staff meeting was held to review Incident Report and emphasized Incidents that occur outside the residential facility. It is to be understood that those other facilities have their responsibility to report it but since the person involved is from our facility, we must do our part as well.
Standard #:	22VAC40-73-210-F
Description:	Based on record review and staff interview, the facility failed to ensure at least two of the required annual hours of training for one of two staff focused on infection control. Evidence: 1. A review of the remote inspection staff document, staff #3's training record (documents) did not include documentation of annual infection control training. Staff #3's date of hire noted as 12-30-18. 2. Staff #1 acknowledge staff's annual infection control not completed.
Plan of Correction:	The Administrator shall make a complete schedule of needed annual training of all staff members. The Director shall designate one staff member to timely file the accomplished training on a timely manner.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the comprehensive individualized service plan (ISP) contained all assessed needs for one of two residents. Evidence: 1. A review of the remote inspection documents for resident #1, the uniformed assessment instrument (uai) dated 7-26-19 indicated resident's psychosocial assessment noted resident's "judgement problems". Further review the uai (dated 4-4-18) indicated resident's behaviorial assessment noted "wandering- passively/ less than weekly". 2. Resident #1, recently wandered away from staff's care on 4-26-20. 3. Staff #1 acknowledged resident ISP did not include resident's assessed needs.
Plan of Correction:	To avoid any oversights of assessments, the Administrator shall involve a team approach for initial and reviews of all assessments. This will include the case manager/social worker, the guardian/parent and one staff member who will be working with the resident directly. This team will help to develop a risk plan for resident number 1.
Standard #:	22VAC40-73-490-D
Description:	Based on document review and staff interview, the facility failed to ensure the healthcare oversight report was completed according the regulation; Evidence: 1. During the remote renewal inspection, a request was made for the healthcare oversight (HCO) on 5-13-20. A second request was made for the report on 5-18-20. The document reviewed did not include the date the reviewer observed and conducted the various areas of the report. The report did not include the date and certification of the individual completing the report. The actions to the recommendations were not submitted with the report. 2. Staff #1 acknowledged the report was not completed as required.
Plan of Correction:	The Administrator shall contract a competent oversight professional to meet all the required needs
Standard #:	22VAC40-73-680-I
Description:	Based on document review and staff interview, the facility failed to ensure the medication administration record (mar) for one of two residents included all required information. Evidence: 1. A review of the remote inspection documents, resident #1's April 2020 medication administration record (mar) did not include the route for the following medicaitons: (a) Lexapro, (b) Benztropine, (c) Oxycarbazepine (d) Invega and (e) Fluphenazine. 2. A review of April 2020's medication administration record (mar) did not include the route for the following medications that were handwritten: (a) Fluphenazine, (b) Oxycarbazepine, (c) Benztropine and (d) Bupropion. 3. Staff #1 acknowledged the documents did not include all required information.
Plan of Correction:	The Administrator reminded the involved Med Tech to correct and review all the requirements needed to administer and document for all medicines. The Administrator shall check this documentation on a weekly basis.
Standard #:	22VAC40-73-690-A
Description:	Based on staff interview, the facility failed to ensure for each resident assessed for residential living care, a licensed health professional, practicing within the scope of his/her profession, shall perform an annual review of all the medications for the residents. Evidence: 1. During remote renewal inspection, a request for the pharmacy review was made. According to staff #1, the facility changed pharmacy and did not have a report from its new pharmacy which reviewed the residents' medication. 2. Staff #1 acknowledged the facility did not have a pharmacy review report.
Plan of Correction:	The Administrator will contact the Head Office of the pharmacy and request for an agreement and plan for the required review, every 6 months. This agreement shall be filed and kept in the medication room. May 22, 2020 June 2nd 2020 will be the first review date.