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: March 24, 2022 , April 1, 2022 , April 19, 2022 and April 25, 2022

Complaint Related: Yes

Areas Reviewed:

Part V: Admission, Retention and Discharge of Residents Part VI: Resident Care and Related Services

Comments:

An unannounced complaint inspection was conducted on 3-24-22 regarding a complaint to the licensing office of a resident not receiving medications and staff clapping hands in face of resident. Interviews were conducted and record review was conducted, information gathered supported the medication allegation, so the complaint is determined to be valid. Please complete the columns for "description of action to be taken' and 'date to be corrected" for each violation cited on the violation notice, and then return a signed and dated copy to the licensing office. If you have any questions, contact your licensing inspector.

Violations:

Standard #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure it did not admit nor retain individuals with psychotropic medication without a treatment plan for a resident. Evidence: 1. Resident #1?s February 2022 medication administration record documented resident is prescribed Paliperidone, Venlafaxine, Buspirone, Lithium Carbonate and Hydroxyzine. The record did not have documentation of a psychotropic treatment plan for the aforementioned psychotropic medications signed by a physician and /or prescriber. 2. Staff #1 acknowledged during the exit meeting on 4-25-22 treatment plan was not in the record for resident #1.
Plan of Correction:	Administrator set up an admission team to ensure all required records and access to prescribers and related pharmacies are in place before admission, without exception. This will ensure all signed prescriptions with applicable diagnosis and signed plans.
Standard #:	22VAC40-73-330-A
Complaint related:	No
Description:	Based on record review and staff interviewed, the facility failed to ensure a mental health screening shall be conducted 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. Evidence: 1. Resident #1 was admitted to a local psychiatric treatment facility on 11-11-21. Resident was admitted to the assisted living facility on 12-12-21. Record did not provide documentation of the mental health screening conducted by a qualified mental health professional nor date of a screening 30 days after admission. 2. Staff #1 acknowledged not having documentation of mental health screening for resident #1.
Plan of Correction:	Administrator set up an admission team to ensure all required records including mental health screening and access to prescribers and related pharmacies are in place before admission, without exception.
Standard #:	22VAC40-73-380-A
Complaint related:	No
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the personal and social information document is kept current. Evidence: 1. Resident #1?s personal and social data document did not document resident?s allergies. The document noted ?NONE? for allergies. The following allergies were documented in the resident?s record: Amoxicillin, Divalproex, Penicillin and Doxycycline, information noted on resident?s uniformed assessment instrument dated 9-29-21. 2. Staff #1 acknowledged document was not updated.
Plan of Correction:	Administrator set up an admission team to include the case manager to ensure functioning needs and allergies are applicable or not applicable to the house. Lwanga House is not accessible for wheelchairs. The team should address proper needs for the Individual Service plan
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) documented all assessed needs for a resident. Evidence: 1. Resident #1?s Uniformed Assessment Instrument (UAI) dated 9-29-21 documented the following needs: bathing, dressing, toileting, transferring, eating/feeding, wheeling, stairclimbing need as human help/ physical assistance (hh/pa). Walking and mobility need assessed as mechanical help/human help/physical assistance (mh/hh/pa). The document also documented resident allergic to the following: Amoxicillin, Divalproex, Penicillin, and Doxycycline. These assessed needs were not on the resident?s ISP dated 12-22-22. 2. Staff #1 acknowledged the assessed needs were not documented on the resident?s ISP.
Plan of Correction:	Administrator set up an admission team to include the case manager to ensure functioning needs and allergies are applicable or not applicable to the house. Lwanga House is not accessible for wheelchairs. The team should address proper needs for the Individual Service plan.
Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the physician or other prescriber orders, both written and oral, for administration of al prescription and over-the counter medications and dietary supplements identify the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident #1?s pharmacy prescription submitted for physician?s orders did not include the diagnosis for the following medications: Paliperidone, Venlafaxine, Buspirone, Lithium Carbonate and Levothyroxine. The resident?s January and February 2022 medication administration record (MAR) also did not include the diagnosis for the aforementioned medications. 2. Staff #1 acknowledged the diagnosis was not on the prescriber?s orders and the resident?s MARs.
Plan of Correction:	Administrator set up an admission team to ensure all required records and access to prescribers and related pharmacies are in place before admission, without exception. This will ensure all signed prescriptions with applicable diagnosis and signed treatment plans.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review and staff interviewed, the facility failed to ensure medication was administered in accordance with the physician?s or other prescriber?s instructions and consistent with the standards of practice outlines in the current medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Resident #1?s February 2022 medication administration record (MAR) noted the following medications not administered: (a) Paliperidone on 2-12-22 thru 2-15-22; (b) Venlafaxine on 2-11-22 thru 2-15-22; (c) Buspirone on 2-14-22 thru 2-15-22 (twice a day); (d) Lithium Carbonate on 2-14-22 thru 2-15-22 (twice a day); (e) Levothyroxine on 2-14-22 thru 2-15-22; and (f) Omeprazole on 2-5-22 thru 2-15-22. 2. Staff #1 acknowledged facility had problems with resident?s medication.
Plan of Correction:	Administrator set up an admission team to ensure all required records and access to prescribers and related pharmacies are in place before admission, without exception.