VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Hamilton
113 Battle Road
Yorktown, VA 23692
(757) 898-1491

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: May 6, 2020 , May 7, 2020 , May 8, 2020 and May 12, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 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 EMERGENCY PREPAREDNESS 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

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 renewal inspection was initiated on 5-7-20 and concluded on 5-12-20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 25. The inspector e-mailed the administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedule, healthcare oversight, health department inspection, fire and emergency drills, oversight by dietitian/nutritionist and new hire since last renewal inspection ( date of hire, sworn statement/affirmation and criminal history record report. 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 #:	22VAC40-73-290-A
Description:	Based on document review and staff interview, the facility failed to ensure the written work schedule included the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. During the remote inspection, a review of the facility's written work schedule for the activity staff noted staff's first name and no job classification. A review of the facility's dietary work schedule did not include staff's job classification. The nursing schedule noted only staff's last name. 2. Staff #1 acknowledged the facility's written work schedule did not include all required information.
Plan of Correction:	All schedules were corrected to include all required information. Staff responsible for scheduling were in-serviced regarding the requirements for including the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. The administrator / designee will audit staff schedules weekly for a period of six weeks to ensure compliance in accordance with the regulation. The Administrator/ designee will review the audit results for patterns and trends and report findings to the Quality Assurance Committee.
Standard #:	22VAC40-73-450-C
Description:	Based on record review and staff interview, the facility failed to ensure the individualized service plan (ISP) included the assessed needs for two of three residents. Evidence: 1. During the remote inspection, resident #1's uniformed assessment instrument (uai) dated 5-10-19 noted dressing as mechanical help/human help/ physical assistance (mh/hh/pa); however, the individualized service plan (ISP) dated 5-10-19 noted physical assistance with getting clothes and help with fastening, shoes, socks and pulling up pants. Resident's toileting need assessed not performed; however, the need is not on the ISP. Transferring needs noted human help/ physical assistance (hh/pa); however, the ISP noted mechanical help/physical assistance (mh/pa), use of arms of chair, bedrail, one or 2 person assistance in/out of bed and into mobile chair. Walking assessed as not performed; however, the ISP noted mechanical assistance (mh), use of electric scooter. Stairclimbing assessed not performed; however the ISP noted mechanical assistance and physical assistance, use of hand-rails and contact guard assistance. Mobility assessed mechanical help (mh); however, the ISP noted mechanical and physical assistance (mh/pa), require assistance transferring to electric scooter, able to steer and guide without assistance. 2. A review of resident #3's uai dated 9-30-19 noted bathing as human help/ physical assistance (hh/pa); however, the ISP dated 2-8-20 noted mechanical assistance (mh), use of grabbar or shower seat/bench. Dressing assessed mechanical and human help/physical assistance (mh/hh/pa); however, the ISP noted no assistance with dressing. Toileting assessed mechanical and human help/physical assistance (mh/hh/pa); however, the ISP noted use of grab bar and raised toilet seat. Transferring assessed mechanical and human help/physical assistance (mh/hh/pa); however, the ISP noted mechanical assistance, use of arm of walker, w/c, chairs, arms of chairs, or pushes up on bed. Bladder assessed no help needed; however, the ISP noted assistance need, incontinent weekly or more, use of undergarment and bed pad. Walking assessed mechanical and human help/physical assistance (mh/hh/pa); however, the ISP noted mechanical assistance (mh), use of walker, staff observe for proper use. Wheeling assessed mechanical/human help/physical assistance (mh/hh/pa); however, the ISP noted use of wheelchair during weakness, able to self-propel without assistance. Stairclimbing assessed mechanical/human help/physical assistance (mh/hh/pa); however, the ISP noted mechanical assistance, use of handrails. 3. Staff #1 acknowledged resident's assessed needs were not the same as the needs on the service plan.
Plan of Correction:	The ISPs for resident #1 and resident #2 were corrected to appropriately identify the needs of the resident. Audits will be conducted of all UAI and ISPs to assure all assessed needs for each resident are appropriately addressed on the ISP. The ISP re-education will be provided to staff responsible for ISPs to assure needs of the resident are appropriately documented. The Director or Nursing/Designee will conduct additional audits commencing after the date of correction for a duration of six weeks to assure that all ISPs completed reflect the assessed needs of the resident. Audit results will be reviewed for patterns and trends and findings reported to the Quality Assurance Committee.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and staff interview, the facility failed to ensure the physician order for administration of a prescription medication shall identify the diagnosis, condition, or specific indications for administering the drug. Evidence: 1. During the remote inspection, a review of resident #1's physician order dated 4-3-20 did not include the diagnosis for skin prep wipes, the document noted "diagnosis exempt". 2. Staff #1 acknowledged the physician order did not include all required information.
Plan of Correction:	The medical record for resident #1 was updated to include diagnosis by the physician. All MARs will be audited to ensure all medication orders have an associated diagnosis. The Director of Nursing/ designee will audit ten MARS monthly for a period of three months to ensure that all ordered medications have a diagnosis listed. The Director of Nursing/ Designee will review audit results for patterns and trends and report findings to the Quality Assurance committee.
Standard #:	22VAC40-73-940-A
Description:	Based on staff interview, the facility failed to ensure it complied with the Virginia Statewide Fire Prevention Code (13VAC5-51) to have an annual inspection conducted by the appropriate fire official. Evidence: 1. On 5-11-20 during the remote inspection, staff #1 was informed that the requested fire inspection document was not received for review. Staff #1 stated, not having a fire inspection since the facility was opened. Staff #1 was informed the last fire inspection was conducted November 2018. 2. The inspector inquired if staff #1 had made contact with the fire official to obtain a fire inspection, as the inspection was past due. The written communication with the fire official was noted on May 6, 2020. 3. Staff #1 acknowledged the facility's last inspection was November 2, 2018.
Plan of Correction:	This plan of correction is respectfully submitted as evidence of alleged compliance. The submission is not an admission that the deficiencies existed or that we are in agreement with them. It is an affirmation that corrections to the areas cited have been made and that the facility is in compliance with participation requirements. The Administrator has made contact with the fire official to obtain a fire inspection and will ensure future compliance wit the Virginia Statewide Fire Prevention Code (13VAC5-51) to have an annual inspection conducted by the appropriate fire official. The Administrator/designee will contact the local fire official prior to the annual date for inspection and maintain records of calls made in the event the fire official is unable to inspect within the annual timeframe. The local fire official has been contacted but at this time due to COVID a date is unknown at this time.
Standard #:	22VAC40-73-970-A
Description:	Based on document review and staff interview, the facility failed to ensure fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC 5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. During the remote inspection, the facility's shift were noted as, 7am---3pm, 3pm---11pm and 11pm--7am. A review of the facility's fire drills for the period of May 7, 2019 through April 5, 2020 were noted as follows: (a) 5-7-19 (10:45 pm); (b) 6-27-19 (10:42 am); (c) 7-9-19 (8:00 pm); (d) 8-7-19 (10:15 am); (e) 9-27-19 (6:15 am); (f) 10-3-19 (3:30 pm); (g) 11-18-19 (10:10 pm); (h) 12-11-19 (6:30 am); (i) 1-21-20 (9:45 am); (j) 1-27-20 (3:00 am); (k) 2-19-20 (6:30 am); (l) 3-27-20 (2:30 pm) and (m) 4-5-20 (10:00 am). 2. Staff #1 acknowledged the drills were not conducted per required shift.
Plan of Correction:	Fire drills will be conducted as required for each shift in a quarter and shall not be conducted in the same month. a schedule has been prepared to ensure future drills are conducted on each shift in a quarter. The Manger/designee has been in-serviced on the importance of conducting drills in accordance with the regulation. The Administrator/designee will conduct audits of all exercises conducted to ensure the drills are conducted as required for each shift in a quarter. The Administrator/ designee will report any trends to the Quality Assurance Committee.