VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vitality Living West End Richmond
1800 Gaskins Road
Henrico, VA 23238
(804) 741-8880

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Sept. 1, 2021 , Sept. 8, 2021 , Sept. 9, 2021 and Sept. 10, 2021

Complaint Related: No

Comments:

A renewal inspection was initiated on September 1, 2021 and concluded on September 10, 2021. The Executive Director was contacted by telephone to initiate the inspection. The Executive Director reported that the current census was 71. The inspector emailed the Executive Director a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, activities calendar, staff schedules, menus, health and fire inspections, fire and emergency drills, criminal record checks, and healthcare and dietary oversights submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on September 9, 2021. An exit interview was conducted with the Administrator and Director of Nursing on September 10, 2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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 #:	22VAC40-73-1120-B
Description:	Based on record review and interview with staff, the facility failed to ensure there were at least 21 hours of scheduled activities available to the residents. Evidence: 1. The September 2021 Activities Calendar was combined with identified as both the Assisted Living and the Safe, Secure Environment (SSE) calendar. There was no documentation of length of activities, and no documentation of which activities were available to the Safe, Secure Environment residents. There were no start and end times or designated length times to show how many hours were for the SSE. 2. Staff #1 confirmed there was no separate activities calendar or documentation that showed 21 hours of scheduled activities for the residents residing in the SSE.
Plan of Correction:	Activities calendar key added to show length of each activity and notation of resident population included in activity. Additional calendar created for SSE residents to accurately reflect their engagement and activity times.
Standard #:	22VAC40-73-490-B
Description:	Based on record review and interview with staff, the facility failed to ensure the licensed health care professional provided health care oversight of the required areas as needed. Evidence: 1. Health care oversights dated 5-16-2021 to 7-16-2021, and 8-19-2021 to 8-25-2021 did not address the following: Ascertain whether a resident's service plan appropriately addresses the current health care needs of the resident; Monitor direct care staff performance of health-related activities; Provide consultation and technical assistance to staff as needed; Review documentation regarding health care services, including medication and treatment records, to assess that services are being provided in accordance with physicians' or other prescribers' orders; Monitor conformance to the facility's medication management plan and the maintenance of required medication reference materials; Evaluate the ability of residents who self-administer medications to continue to safely do so; Observe infection control measures and consistency with the infection control program of the facility. 2. Additionally, the health care oversight 8-19-2021 to 8-25-2021 was blank in of the aforementioned areas and also including not addressing staff training needs. 3. Staff #1 during interview acknowledged the health care oversights did not contain the required information for oversight requirements.
Plan of Correction:	Health care oversights form will be updated to include additional details to ascertain whether a resident's service plan appropriately addresses the current health care needs of the resident; Monitor direct care staff performance of health related activities; Provide consultation and technical assistance to staff as needed; Review documentation regarding health care services, including medication and treatment records, to assess that services are being provided in accordance with physicians' or other prescribers' orders; Monitor conformance to the facility's medication management plan and the maintenance of required medication reference materials; Evaluate the ability of residents who self-administer medications to continue to safely do so; Observe infection control measures and consistency with the infection control program of the facility. Additionally, training records were updated to correctly reflect missing training dates on the Healthcare Oversight form, as all training was completed in timely manner but not documented on this form. Dates were documented in separate system ? this information was used to correct written documentation.
Standard #:	22VAC40-73-490-D
Description:	Based on record review and interview with staff, the licensed health care professional who provided the health care oversight failed to identify the specific residents for whom the oversight was provided. All of the requirements of this subsection shall be in writing and maintained in the facility files for at least two years, with any specific recommendations regarding a particular resident also maintained in the resident's record. Evidence: 1. The health care oversights reviewed with the dates of 2-15-2021 to 3-23-2021, 5-16-2021 to 7-16-2021, and 8-19-2021 to 8-25-2021 did not contain the names of any residents for whom the oversight was provided. 2. Staff #1 confirmed during interview the residents? names for the health care oversight were not provided.
Plan of Correction:	Records were updated to correctly reflect missing resident names on the Healthcare Oversight form, as all ISP reviews were completed in timely manner but not documented on this form. Names were documented in separate system ? this information was used to correct written documentation.
Standard #:	22VAC40-73-520-E
Description:	Based on record review and interview with staff, the facility failed to ensure there shall be at least 14 hours of scheduled activities available to the residents each week for no less than one hour each day. Evidence: 1. The facility?s September 2021 Activities calendar did not indicate the time frame of scheduled activities. Additionally, there was not delineation between the Assisted Living and Safe Secure Environment activities. There were no lengths of times provided on the calendar. 2. Staff #1 confirmed during interview that the Activities calendar did not identify the length of time for any activities listed.
Plan of Correction:	Activities calendar key added to show length of each activity and notation of resident population included in activity. Additional calendar created for SSE residents to accurately reflect their engagement and activity times.
Standard #:	22VAC40-73-520-I
Description:	Based on record review and interview with staff, the facility failed to provide a written schedule of activities that met criteria including the type and hour of the activity. Evidence: 1. The September 2021 activities calendar did not document the type of activity or specific hour of activity, as neither morning (a.m.) or evening (p.m.) was documented on the calendar. 2. Staff #1 confirmed during interview that the activities calendar did not contain the required information.
Plan of Correction:	Activities calendar updated to included AM and PM notations.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and interview with staff, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #7?s date of hire was 5-14-2021. Staff #7 did not have a criminal history record report on file as of the date of the inspection (9-08-2021). 2. Section 63.2-1720 of the Code of Virginia requires all employees of assisted living facilities, as defined by ? 63.2-100 of the Code of Virginia, to obtain a criminal history record report from the Department of State Police. During review of the new hire staff criminal history record reports, 19 of the criminal history record reports were not obtained from the Department of State Police, but the US Criminal record search. 3. Staff #1 confirmed during interview that 19 of the newly hired staff?s criminal history record reports were not obtained from the Department of State Police. 4. Staff #1 confirmed Staff #7?s criminal history record report had not been completed by the 30th day of employment.
Plan of Correction:	All employees had Federal background checks completed prior to first day of employment in the place of the state level check. Due to transition in management company, there was a waiting period while new credentials were requested for running state background checks. Request was made on 8/18/21 to set up the account. 9/1/2021 request agreement form was sent. 9/21/21, we ran all Virginia state background checks for all new employees since February 2021.