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 26, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 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 EMERGENCY PREPAREDNESS 63.2 Protection of adults and reporting. 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 the licensing staff using an alternate remote protocol necessary due to the state of emergency health pandemic declared by the Governor of Virginia. A monitoring inspection was initiated on 4-30-21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that current census was 23. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three staff records, three resident records, healthcare oversight, nutrition report, staff schedules, sworn disclosure and criminal record report and fire and emergency drills also fire and health inspections. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-250-D
Description:	(250-D-2.c) Based on record review and staff interview, the facility failed to ensure one of three staff person annually submit the results of a risk assessment, documenting that the individual was free of tuberculosis (TB) in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. On 5-3-21, staff #6?s submitted staff record did not include documentation of an annual risk assessment, documenting the staff was free of tuberculosis (TB) in a communicable form. The TB document submitted was dated 12-7-19. Staff #6?s date of hire is documented as 12-20-19. 2. On 5-7-21, the additional requestee TB document received for staff #6 documented a TB screening dated 12-30-19. 3. On 5-11-21, staff #2 acknowledged, staff #6 did not have an annual TB risk assessment.
Plan of Correction:	Staff #6?s record was updated with the annual TB risk assessment. All staff records were audited to ensure the annual TB risk assessments are complete. Staff responsible for employee paperwork were in-serviced regarding the requirements for an annual TB risk assessment. The administrator / designee will audit staff files monthly for a period of six months 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 #:	22VAC40-73-290-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. On 5-3-21, the facility staff schedules submitted did not include documentation/ indication of whomever is in charge at any given time. 2. On 5-6-21, staff #2 acknowledged, the facility staff schedules submitted for review did not indicated whomever is in charge at any given time.
Plan of Correction:	The master schedule template was updated to include an indication of staff member in charge at any given time. Staff responsible for scheduling were in-serviced regarding the requirements for including 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. Additionally, the Administrator/designee will audit staff schedules quarterly to ensure continued compliance. 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 all assessed needs for two of three residents. Evidence: 1. On 5-3-21, resident #2?s individualized service plan (ISP) dated 11-29-20 did not include resident?s physical and occupational therapy services. Resident?s physical examination dated 9-28-20 documented services evaluation and treat order. Resident?s ISP documented resident?s diet as regular and no added salt (NAS). The nutrition report dated 1-14-21, resident?s diet documented as mechanical soft. 2. On 5-7-20 the additional requested documents noted a mechanical soft diet dated 10-2-20. The additional requested document also noted resident?s physical therapy and occupational therapy services order dated 10-2-20. 3. Resident #2?s uniformed assessment instrument (UAI) dated 10-20-20 documented bowel assessed as weekly or more, however, this assessed need is not addressed on the ISP. Walking is assessed as mechanical help/ human help (physical assistance), however, the ISP did not include human help (physical assistance). 4. Resident #3?s UAI dated 12-25-20 documented stairclimbing assessed as mechanical help/ human help (physical assistance), however, the ISP did not include human help/physical assistance. 5. On 5-11-21, staff #2 acknowledged all assessed needs for residents #2 and #3 were not documented on the resident?s ISP.
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 ISPs for resident #2 and resident #3 were corrected to appropriately identify the needs of the resident. Audits will be conducted of all UAIs and ISPs to assure all assessed needs for each resident are appropriately addressed on the ISP. Education will be provided to staff responsible for resident ISPs & UAIs to ensure assessed needs of the resident are appropriately documented on the ISP & UAI. The Director of Nursing/Designee will conduct 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. Additionally, the Director of Nursing/Designee will audit 20% of resident UAIs & ISPs quarterly to ensure assessed needs are appropriately documented. Audit results will be reviewed for patterns and trends and findings reported to the Quality Assurance Committee.