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: Aug. 16, 2022 , Aug. 22, 2022 , Aug. 26, 2022 , Sept. 1, 2022 and Sept. 7, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES

Comments:

Type of inspection: Monitoring An unannounced on-site monitoring inspection was conducted on 8-16-22-22 (AR 06:50 a.m./dep 10:00 a.m.) The facility census was 2. A tour of the facility was conducted, emergency preparedness standards were reviewed and observed, first aid kit check, breakfast meal observed, medication pass observation conducted, staff and resident interviews and records were reviewed. An exit meeting was conducted with the administrator in charge. The Acknowledgement of Inspection form was sent via email for the Administrator to review and sign on 8-16-22 and 8/26/22.The final exit meeting will be scheduled. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Willie Barnes, Licensing Inspector at 757-439-6815 or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-B-8
Description:	Based on observation and staff interviewed, the facility failed to ensure the current license was posted in the facility in a place conspicuous to the residents and the public. Evidence: 1. On 8-16-22 the license posted in the facility was dated June19, 2022. 2. Staff #1 acknowledged the current license was not posted.
Plan of Correction:	Current License was retrieved and posted by Administrator
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility to ensure it did not admit or retain individuals with psychotropic medications without appropriate treatment plans for a resident. Evidence: 1. A medication pass observation was conducted on 8-16-22 for resident #1. The August 2022 medication administration record (MAR) documented psychotropic medications. A request for treatment plans were requested. The treatment plans received on 9-1-22 was dated 8-29-22. 2. Staff #1 acknowledged the treatment plans for psychotropic medications were not available for the aforementioned residents.
Plan of Correction:	A full treatment plan for resident #1 was completed by the Administrator
Standard #:	22VAC40-73-520-H
Description:	520-H.4 Based on observation and staff interviewed, the facility failed to ensure the current month?s schedule shall be posted in a conspicuous location in the facility or otherwise be made available to residents and their families. Evidence: 1. On 8-16-22, the current month?s activity schedule posted in the facility was dated March 2022. 2. On 8-16-22, staff #2 acknowledged the current month?s activity calendar was not posted.
Plan of Correction:	Current Activity Calendar was retrieved and posted by House Manager
Standard #:	22VAC40-73-610-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the menu for meals and snacks posted was current. Evidence: 1. On 8-16-22, the menu posted in the facility was dated March 29, 2022 through April 11, 2022. 2. On 8-16-22, staff #2 acknowledged the current menu was not posted.
Plan of Correction:	The relevant menu was retrieved and posted by the House Manager
Standard #:	22VAC40-73-680-I
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the medication administration record included all required information. Evidence: 1. On 8-16-22, during the medication pass observation with staff #2, resident #2?s August 2022 medication administration record (MAR) did not include the diagnosis, condition, or specific indications for administering the drug or supplement for the following: Clonazepam, Trazodone, Olanzapine and Hydroxyzine. 2. On 8-16-22, staff #2 acknowledged the diagnosis for the aforementioned resident?s medications were not on the August 2022 MAR.
Plan of Correction:	The administrator/Med Tech revised the MAR and included all required information