VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brookdale Virginia Beach
937 Diamond Springs Road
Virginia beach, VA 23455
(757) 493-9535

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Sept. 30, 2020 , Oct. 1, 2020 , Oct. 2, 2020 , Oct. 6, 2020 and Oct. 7, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

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 complaint inspection was initiated on 09-30-2020 and concluded on 10-07-2020. A complaint was received by the department regarding allegations in the areas of Staffing and Supervision, Resident Agreement with Facility and Monthly statement of charges and payments, Personal Care Services and General Supervision of Care, and Individualized Service Plans. The Interim Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Interim Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on record review and interview, the licensee failed to ensure compliance with the facility?s policies and procedures. Evidence: 1. Staff #1 provided the ?Residency Agreement? for resident #2 (dated 12-08-2016), resident #3 (dated 11-25-2019); and resident #4 (dated 12-27-2017) which documented ?? Rate Changes. We will provide thirty (30) days written notice of any change in the rates or pricing method for Basic Services, Personal Services, Select Services, and Therapeutic Services. We may offer or require a change in Personal Service Plan when we determine additional services are requested or required. The new Personal Service Rate resulting from a change in your Personal Services Plan is effective immediately after written notice is given?? 2. Staff #1 provided copies of resident #2, resident #3, and resident #4`s July, August, and September 2020 monthly billing statements. The billing statements documented an increase in rates for Personal Care Services: A. Resident #2?s July 2020 statement documented a ?Personal Service Rate? of $3,506.00. The August 2020 statement and September 2020 statement documented a ?Personal Service Rate of $3,980.00.? B. Resident #3?s July 2020 statement documented a ?Personal Service Rate? of $1,885.00. The August 2020 statement and September 2020 statement documented a ?Personal Service Rate of $3,419.00.? C. Resident #4?s July 2020 statement documented a ?Personal Service Rate? of $3,496.00. The August 2020 statement and September 2020 statement documented a ?Personal Service Rate of $3,555.00.? 3. When asked to provide documentation of the written notice of changes in the rates or pricing for Personal Services to Residents #2, #3, and #4?s or to their legal representative, staff #1 stated the changes were noted on the Residents Individualized Service Plans (ISP?s). Resident #2?s current ISP dated 07-28-2020, Resident #3?s current ISP dated 08-25-2020, and Resident #4?s current ISP dated 08-31-2020 did not document changes in the rates or pricing for Personal Services. 4. Staff #1 could not provide documentation of a 30 day written notice of any change in the rates or pricing method for Basic Services, Personal Services, Select Services, and Therapeutic Services for Residents #2, #3, or #4.
Plan of Correction:	? The Executive Director or Designee will provide retraining to Business Office Manager and Health & Wellness Director on process of written notification to the resident/legal representative of rate or pricing method change for Basic Services, Personal Services, Select Services, and Therapeutic Services. ? The Business Office Director or Designee will maintain documentation in resident records of written notification given of any rate or pricing method change for Basic Services, Personal Services, Select Services and Therapeutic Services. ? To assist with ongoing compliance, the Executive Director or Designee will audit random resident records to ensure written notification is given with any change in the rates or pricing method for Basic Services, Personal Services, Select Services and Therapeutic Services once a month for three (3) months.
Standard #:	22VAC40-73-460-D
Complaint related:	No
Description:	Based on record review and interview, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs to prevent wandering from the premises. Evidence: 1. On 09-15-2020, staff #1 emailed an incident report involving resident #1?s elopement from the special care unit. The incident report documented ?Resident was noted outside of the building off of the property [on 09/14/2020 at approximately 12:50 PM]. Elopement protocol implemented and resident found by staff without injury.? 2. The facility?s ?Incident Investigation? form dated 09-14-2020 documented ?1:10pm- med tech could not locate resident #1; 1:32- Resident located at a [local] pizza restaurant and had arrived at approximately 1 pm?? Additionally, Resident #1?s ?Progress Notes? dated ?09/14/2020? documented ?Resident left the building around 1 ish, he was found at the [local] pizza restaurant for 45 mins?? The distance from the facility to the local pizza restaurant is approximately 0.1 miles; and the roads that surround the facility are: Diamond Springs Road and Wesleyan Drive with a speed limit range of 35 mph to 45 mph. 3. Additional documentation reviewed documented resident #1?s wandering behaviors: A. An incident report dated 06-25-2020 documented ?Resident wandered on toward sidewalk in front of community [on 06-24-2020 at approximately 11:15 AM]. Staff immediately went to resident, assessed resident for c/o and injuries - no injuries, all exit doors are being evaluated by maintence.? B. Resident #1?s Uniform Assessment Instrument (UAI) dated 06-24-2020 (and updated on 09-14-2020) documented the resident has wandering behaviors weekly or more and ?exhibits exit seeking behaviors.? 4. Staff #1 acknowledged that ?resident #1 had wandering/exit seeking behaviors on the UAI prior to the elopement incident on 09-14-2020.?
Plan of Correction:	? The Executive Director or Designee will provide retraining on reducing the risk of elopement to current clinical staff no later than 3/15/2021. ? The Health & Wellness Director or designee will review UAI of current residents to identify residents with wandering or exit seeking behaviors no later than 3/15/2021. ? The Executive Director or Designee hired and trained day shift receptionist in November 2020. This has made a positive impact for the residents and community. ? To assist with ongoing compliance, the Maintenance Director or Designee will conduct elopement drills for each shift once a month for three (3) months.