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: May 10, 2021

Complaint Related: No

Areas Reviewed:

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 EMERGENCY PREPAREDNESS 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

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 4-14-21 and concluded on date 4-23-21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was five. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two staff records, two resident records, staff schedule, health and fire inspection, fire drills and health care oversight documents. 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 #:	22VAC40-73-210-F
Description:	Based on record review and staff interview, the facility failed to ensure when adults with mental impairments reside in the facility, at least four of the required training hours shall focus on topics related to residents' mental impairments. Evidence: 1. Staff #2's training record submitted on 4-18-21, did not include at least four hours of training on topics related to residents' mental impairments. 2. On 4-19-21, additional staff training documents was requested from staff #1. 3. On 4-23-21, staff #1 acknowledged, staff #2's training record submitted did not include 4 hours of training in mental impairments.
Plan of Correction:	The administrator has made an annual mandatory training schedule for mental health for all staff members. This will eradicate loopholes due to other trainings.
Standard #:	22VAC40-73-290-A
Description:	Based on record review and staff interview, the facility failed to ensure the written work scheduled included the names and job classification of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. The written staff scheduled submitted on 4-18-21 did not include the job classification of staff listed. The schedule also did not indicate whomever was in charge at any given time. 2. On 4-19-21, staff #1 acknowledged the written staff schedule did not include all required information.
Plan of Correction:	The administrator has written up a corrected work schedule that includes names of staff members and their job classification on every shift with an indication of who is charge of that particular shift.
Standard #:	22VAC40-73-310-A
Description:	Based on record review and staff interview, the facility failed to ensure it did admit or retain a resident who requires a level of care or service or types of services for which the facility is not licensed or which the facility does not provide. Evidence: 1. Resident #1, uniformed assessment instrument (UAI) dated 8-28-20 documented resident met criteria for nursing facility. The document also documented resident's DMAS 96 form completed for long term care placement. The UAI also documented the resident's placement for a nursing facility was made and accepted. 2. On 4-19-21, staff #1 was not aware of the information documented in the resident's UAI. Resident's assessment for nursing facility does not meet the facility's current license as an assisted living facility. 3. On 4-19-21 and 4-23-21, staff #1 acknowledged the resident's assessment is not for an assisted living facility.
Plan of Correction:	The administrator has assigned 2 staff members to properly review discharge/intake documents before admission. This team will ensure that only assisted Living candidates will be allowed for admission to our facility.
Standard #:	22VAC40-73-310-H
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit or retain individuals with psychotropic medications without appropriate treatment plans for two residents. Evidence: 1. Resident #1's March 2021 medication administration record (MAR) submitted on 4-18-21 documented the following psychotropic mediations: Divalproex Sodium (Depakote) and Quetiapine Fumarate (Seroquel) without a diagnosis. 2. Resident #2's March 2021 medication administration record (MAR) submitted on 4-18-21 documented the following psychotropic medications: Clozapine, Propanolol, Benztropine, Trazodone and Haloperidol Deconate. 3. On 4-19-21, the inspector requested staff #1 provide the treatment plans for residents' #1 and #2. 4. On 4-23-21, staff #1 acknowledged the facility did not have signed and dated treatment plans for residents #1 and #2 prior to the inspection date of 4-19-21.
Plan of Correction:	The administrator has assigned 2 staff members to put together applicable treatment plans for new admissions and to revise treatment plans on an ongoing basis.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and staff interview, the facility failed to ensure the admission physical examination contained all of the required information for one of two residents. Evidence: 1. Resident #1, physical examination dated 9-26-20 did not include the resident's blood pressure. 2. On 4-19-21, staff #1 acknowledged the physical examination did not include the resident's blood pressure.
Plan of Correction:	The administrator has assigned two staff members to thoroughly review the physical examination record of new admissions for completed necessary details on the record.
Standard #:	22VAC40-73-330-A
Description:	Based on record review and staff interview, the facility failed to ensure it conducted a mental health screening prior to admission if behaviors or patterns of behavior occurred within the previous six months that were indicative of mental illness, intellectual disability, substance abuse, or behavioral disorders and that caused, or continue to cause, concern for the health, safety, or welfare either of that individual or others who could be placed at risk of harm by that individual. If not possible for the screening to be conducted prior to admission, the individual was admitted without documentation the reason for the delay and the screening was not conducted as soon as possible, but no later than 30 days after admission. Evidence: 1. Resident #1's uniformed assessment instrument (UAI) dated 8-28-20 documented resident TDO/ECO'd to a private hospital prior to resident's admission to the facility on 10-3-20. Resident #1's record did not contain documentation of the mental health screening prior to admission. The record also did not include documentation of the reason for the screening delay and screening completion within 30 days after admission. 2. On 4-19-21 and 4-23-21, staff #1 acknowledged the facility did not have a mental health screening for resident #1 and documentation of reason for delay as required per the regulation.
Plan of Correction:	The administrator has assigned two staff members who will ensure that proper mental health screening has been accomplished for individuals before admission into our facility.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the resident's individualized service plan included all assessed needs for one of two residents. Evidence: 1. Resident #1' uniformed assessment instrument (UAI) dated 8-28-20 documented needs assessed for activities of daily living and ambulation needs . These assessed needs were not documented on the resident's individualized service plan dated 10-3-20. 2. According to staff #1 and guardianship document provided to the inspector, the resident has a local agency who has been appointed guardianship for resident #1. This information was not documented on resident #1's ISP. 3. Resident #3's admitting physical examination dated 9-26-20 documented resident is allergic to shellfish and Penicillin. This information was not documented on the resident's ISP. Resident #2's medication administration record (MAR) for March 2021 documented allergy to Penicillin. This information was not documented on resident's ISP. 4. Staff #1 acknowledged on 4-19-21, all assessed needs for residents were not documented on the individualized service plan (ISP).
Plan of Correction:	The administrator has assigned 2 staff members who will review individual?s needs according to Uniformed Assessment instrument and reference all these needs on the individual?s service plan.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements included all requirements. Evidence: 1. Resident #1's admission physical dated 8-28-20 listed the following medications without a diagnosis: Atarax, Depakote ER, Melatonin and Seroquel. 2. Resident #1's physician's orders submitted on 4-18-21 did not include the diagnosis for the aforementioned prescribed medications. 3. Staff #1 acknowledged on 4-19-21 and 4-23-21 resident #1's physician's orders did not include diagnosis.
Plan of Correction:	The administrator has assigned two staff members to review all physician orders and underline appropriate diagnosis with appropriate Doctor?s signature. This will be done before admission and ongoing at the facility, whenever the doctor prescribes a new or revised prescription
Standard #:	22VAC40-73-680-K
Description:	Based on record review and staff interview, the facility failed to ensure the use of PRN medications were administered following conditions per the regulations Evidence: 1. Resident #2's March 2021 medication administration record (MAR) documented PRN Trazadone, 1 to 2 tabs at bedtime. The physician's orders dated 10-9-19, 11-12-19, 2-5-20 and 3-10-21 also documented 1 to 2 tabs. Physician order dated 7-24-20 and 4-12-21 documented Trazadone 50 to 100 mg tablet at bedtime. 2. The physician's orders for Trazadone for resident #1 did not include exact dosage per the regulation when medication aides administer the PRN medications. 3. Staff #1 acknowledged on 4-19-21 and 4-23-21, the PRN physician's order for resident #1 did not include the exact dosage.
Plan of Correction:	The administrator has assigned two staff members to ensure the use of PRN medications with an attached proper dose and an applicable doctor?s signature. This will be done before admission and whenever doctor indicates the PRN change.