VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Traway Assisted Living Home AKA Synergy Community Supports, LLC
8001 Traway Court
Chesterfield, VA 23235
(804) 938-0667

Current Inspector: Yvonne Randolph (804) 662-7454

Inspection Date: March 4, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

An unannounced monitoring inspection was conducted 3/4/2020 from approximately 9:30 am to 11:10 am. The facility reported three residents in care, two resident files and three staff files were reviewed for compliance. All new personnel records were reviewed since the last inspection for criminal history record reports,one staff did not have a criminal history record report. Please complete the "plan of correction" and "date to be corrected" for the violation cited on the violation notice and return to the Inspector within 10 days. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard, 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). See violation notice for non-compliance

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on a three staff file reviews and an interview with the administrator, the facility failed to maintain required personal and social data information for two staff. Evidence: Criminal background checks, orientation, job descriptions were not found during the file reviews for staff # 1 and # 3 on 3/4/2020. The administrator confirmed that the personal and social data information had not been secured and/or completed.
Plan of Correction:	Background checks on both were not placed in correct file. One staff filled out the form but had it sent to her. The administrator will carefully monitor background checks . Additionally, the administrator job descriptions will be placed in staff members' files.
Standard #:	22VAC40-73-250-D
Description:	Based on a file review and an interview with the administrator, the facility failed to secure a tuberculosis screening for one staff on or within seven days prior to the first day of work at the facility. Evidence: The documented date of hire for staff # 3 is 12/17/2019. A tuberculosis screening was not found during the file review on 3/4/2020. The administrator confirmed that a tuberculosis screening had not been secured.
Plan of Correction:	The staff did have a TB test bit it was not placed in the correct file. The administrator will monitor staff that are responsible for placing test in folders.
Standard #:	22VAC40-73-310-D
Description:	Based on a file review and an interview with the administrator, the facility administrator failed to provide written assurance to one resident that the facility has the appropriate license to meet his care needs at the time of admission. Evidence: Resident # 1 was admitted to the facility on 11/9/2019, a written assurance was not found during the file review on 3/4/2020. The administrator confirmed that a written assurance had not been completed. Evidence: Resident # 1 was admitted to the facility on 11/9/2019, a plan of care was not found during the file review on 3/4/2020. The administrator confirmed that a plan of care had not been completed.
Plan of Correction:	The resident was admitted to the home and was then admitted to the hospital a day later. After a week in the hospital he returned back to the home. He again had to return to the hospital two additional times. His condition has now stabilized. His doctor commended the administrator for his excellent care that attributed to his recovery. Written plans were followed from the doctor but the administrator will place the care plans on the proper forms.
Standard #:	22VAC40-73-320-A
Description:	Based on a file review and an interview with the administrator, a physical examination and tuberculosis screening was not completed for one resident within the 30 days preceding admission. Evidence: Resident # 1 was admitted to the facility on 11/9/2019. The physical examination and tuberculosis screening for resident # 1 were completed after admission. The tuberculosis screening found in the file for resident # 1 was dated 12/1/2019. The physical examination in the file of resident # 1 was dated 11/25/2019.
Plan of Correction:	The resident's admission date was changed to 11/26/2019 by the prior facility. The administrator will correct all dates and monitor dates more closely.
Standard #:	22VAC40-73-325-B
Description:	Based on a file review and an interview with the facility's administrator, a fall risk rating was not completed after a fall for one resident. Evidence: Resident # 2 had a recent fall. There was no documentation of the completion of a fall risk rating after the fall.
Plan of Correction:	The administrator voluntarily told the inspector about a resident's fall. The administrator will complete the proper form and submit to Social Services.
Standard #:	22VAC40-73-390-A
Description:	Based on a file review and an interview with the administrator, a written agreement was not completed at or prior to the time of admission for one resident. Evidence: Resident # 1 was admitted to the facility on 11/9/2019, a written agreement was not found during the file review on 3/4/2020. The administrator confirmed that a plan of care had not been completed.
Plan of Correction:	The written agreement was not in the correct file. The administrator will check and monitor staff so that all documents are placed together.
Standard #:	22VAC40-73-440-A
Description:	Based on a file review and an interview with the administrator on 3/4/2020, the facility failed to complete a uniform assessment instrument (UAI) prior to admission. Evidence: Resident # 1 was admitted to the facility on 11/9/2019, the UAI found in the file was not signed or dated. The administrator confirmed that the UAI was incomplete.
Plan of Correction:	The UAI was to have been completed and dated by a staff member. The administrator will monitor all files.
Standard #:	22VAC40-73-450-A
Description:	Based on a file review and an interview with the administrator, neither a preliminary or comprehensive plan of care was not developed on or within seven days prior to the day of admission for one resident. Evidence: Resident # 1 was admitted to the facility on 11/9/2019, a plan of care was not found during the file review on 3/4/2020. The administrator confirmed that a plan of care had not been completed.
Plan of Correction:	The resident's ISP was in his file. However, it was overlooked because there were so many notes from his rehabilitation and hospital admissions. The administrator will instruct staff to place all prior facility notes in a separate section and will monitor it more closely.
Standard #:	22VAC40-73-550-G
Description:	Based on three staff file reviews and an interview with the administrator, the facility failed to document an annual review of the rights and responsibilities of residents in assisted living facilities for one staff. Evidence: The documented date of hire for staff # 2 is 1/1/2016. An annual rights review was not found for staff # 2 during the file reviews on 3/4/2020. The administrator confirm an annual rights review was not documented.
Plan of Correction:	The administrator will document annual review of rights and responsibilities and even though it was reviewed verbally place written document in file. Place written document in file.
Standard #:	22VAC40-73-950-F
Description:	Based on an interview with the facility's administrator, the facility failed to review the emergency preparedness plan annually. Evidence: There was no documentation to support an annual review of the emergency preparedness plan. The administrator confirmed during the interview that an annual review had not been completed.
Plan of Correction:	There was no written documentation for the review of the annual emergency plan, but the administrator discussed the plans with each staff member individually and showed and showed them where the plans were located. The administrator will devise a form and have staff sign and date the form.