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 10, 2022 , May 12, 2022 and May 24, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

Type of inspection: Renewal On-site renewal inspection conducted with two inspectors from the Peninsula Licensing Office on 5-10-22 (Ar 08:00 /dep 6:00 p.m.) The facility census was 33, a tour of the facility was conducted, medication pass observation, activity, emergency preparedness/ first aid kit check, resident and staff records and interviews conducted. A preliminary exit conducted with administrator and other facility representatives on 5-10-22. Requested documents received on 5-12-22. Review of violations with administrator and staff on 5-24-22 and requested documents received on 5-24-22. Preliminary also conducted with administrator and Director of nursing on 6-6-22. Final exit interview with administrator scheduled for 6-6-22 (1:15 p.m.) The Acknowledgement of Inspection form was sent to the Administrator following each exit meeting. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. The department's inspection findings are subject to public disclosure. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact (Willie Barnes), Licensing Inspector at (757-439-6815) or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure staff attend at least 12 hours of annual training, at least two of the required hours of training shall focus on infection control and prevention. When adults with mental impairments resident in the facility, at least four of the required hours shall focus on topics related to residents? mental impairments for one of three staff records reviewed. Evidence: 1. Staff #5?s training record provided documented 7.0 of the required 12 hours of training, 1 of 2 hours of infection control and prevention and 3 of 4 hours of mental health training. Staff #5?s date of hire was documented as 9-14-16 with the agency and 3-11-20 to the assisted living facility. 2. Staff #1 acknowledged the aforementioned staff member did not have required annual training.
Plan of Correction:	1. Staff #5?s training is updated to reflect requirements for annual training. 2. Staff training records will be audited to ensure the appropriate training topics and education hours have been completed annually per regulation. The team will be educated on the required education topics, hours and completion requirements. 3. The Administrator/ designee will conduct a monthly audit of all staff training records for 3 months. Audit results will be reviewed for patterns and trends, and findings will be reported to the leadership team.
Standard #:	22VAC40-73-260-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure each direct care staff member shall maintain current certification in first aid. Each direct care staff member who does not have current certification in first aid shall receive certification within 60 days of employment. Evidence: 1. The posted first aid and Cardiopulmonary resuscitation (CPR) did not include a date for staff #7 and #8. Staff #7?s first aid and CPR documents submitted did not meet the requirements of regulation (22VAC40-260-A.1). Staff?s date of hire documented as 3-13-21. 2. Staff #9?s date of hire was documented as 5-24-21, documentation of first aid not available. 3. Staff #1 acknowledged the aforementioned staffs? record did not include the required first aid training
Plan of Correction:	1. Staff #7 and #8 are currently out on leave, and will complete authorized first aid and CPR training prior to returning to work. Staff #9 no longer works at the facility. 2. Staff records were audited to ensure that all CPR and first aid certifications are from authorized source per the standard. A first aid class has been scheduled in the facility for all staff who need new or renewal of first aid training and certification and will be scheduled as needed thereafter. Education will be provided to team members involved in onboarding and personnel record maintenance to ensure all first aid and CPR staff training is completed per standards. Staff will be in-serviced regarding the authorized sources that are acceptable per standard for first aid and CPR certification. 3. The Administrator/designee will conduct a monthly audit for three months to ensure all staff has first aid and CPR certification from an authorized source per standards within the designated time frame. Audit results will be reviewed by the Administrator/ designee for patterns and trends and findings reported to the leadership team.
Standard #:	22VAC40-73-290-A
Description:	Based on document and staff interviewed, the facility failed to ensure the written work schedule includes the names and job classification of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: 1. The dietary schedule did not include the job classification of staff and only the first name of staff documented. 2. Staff #1 acknowledged the dietary scheduled did not include all required information.
Plan of Correction:	1. The master schedule templates, to include dietary staff, were updated to include last name, first initial, and job title at any given time. 2. Dietary manager will be educated regarding the requirements for including an indication of who is working and their job title reflected on the schedule. 3. The Administrator/ designee will audit staff schedules weekly for a period of six weeks to ensure compliance with regulation.
Standard #:	22VAC40-73-310-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure in accordance with 63.2-1805- D of the Code of Virginia, it did not admit or retain individuals with any of the prohibited conditions or care needs. Evidence: 1. Resident #5?s record included orders for the following psychotropic medications, Haloperidol and Lorazepam. On 5-10-22, the resident?s record did not have a treatment plan for these medications. 2. Staff #1 acknowledged the aforementioned resident?s record did not have a psychotropic treatment plan for the aforementioned psychotropic medications.
Plan of Correction:	1. Resident #5?s medication orders had been reviewed and updated by physician. Appropriate treatment plan is in place for resident #5?s psychotropic medications. Resident records had been audited for correctness and completion of psychotropic medication treatment plans. 2. Resident coordinator and manager will be re-educated regarding the accuracy of process for ensuring the facility does not admit or retain individuals with prohibited conditions or care needs, to include psychotropic medications. 3. Director of Nursing/ designee will review all new residents and psychotropic medication orders for 3 months to ensure the facility does not admit or retain individuals with prohibited conditions or care needs Audit results will be reviewed by the Director of Nursing/ designee for patterns and trends and findings reported to the leadership team.
Standard #:	22VAC40-73-320-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the resident?s admitting physical examination included all information required per the regulation. Evidence: 1. Resident #5?s physical examination dated 3-30-22 did not include the date of the examination and the address and phone information was also not documented on the form. 2. Staff #1 acknowledged the aforementioned resident?s admitting physical examination document did not include all required information.
Plan of Correction:	Resident # 5?s admitting physical examination was updated with the correct date, physician?s address, and phone number. 2. Resident physical examination records were audited to ensure the residents physical examination included all the information required, to include the physicians address and phone number. Resident coordinator will be re-educated to ensure completeness of resident physical examination records prior to admission. 3. Resident physical examination records will be audited for all new admissions for 3 months. Audit results will be by the Director of Nursing/designee reviewed for patterns and trends and findings reported to the leadership team.
Standard #:	22VAC40-73-440-D
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure for private pay individuals, the uniformed assessment instrument (UAI) shall be completed as required by 22 VAC for two of six records reviewed. Evidence: 1. Resident #1?s uniformed assessment instrument (UAI) dated 8-20-21 was completed by staff #4, but not signed by a designee or administrator. 2. Resident #6?s UAI dated 10-1-21 was completed by staff #4, but not signed by a designee or administrator. 3. Staff #1 acknowledged the aforementioned UAI was not completed as required.
Plan of Correction:	1. Resident #1 and resident #6?s UAI were updated to include the signature of the administrator/ designee. 2. Resident UAI?s were audited to verify administrator/ designee?s signature are in place. The resident coordinator will be re-educated on completeness of the UAI to include the signature and date of the administrator/ designee when the assessment is completed. 3. Resident UAI?s will be audited weekly by the Director of Nursing/ designee for 6 weeks to ensure completeness of all UAI?s, including appropriate signatures and dates. Audit results will be reviewed by the Director of Nursing/ designee for patterns and trends and findings reported to the leadership team.
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s individualized service plan (ISP) included all assessed needs for five of six residents? records. Evidence: 1. Resident #2?s uniformed assessment instrument (UAI) dated 1-25-22 documented wheeling as mechanical help. The ISP documented resident required physical assistance by staff to push wheelchair. 2. Resident #3?s personal and social data noted resident is an organ donor. The resident?s ISP dated 10-8-21 did not included this information. 3. Resident #4?s uniformed assessment instrument (UAI) dated 3-18-22 documented resident?s behavior as appropriate. The resident?s record documented resident?s desire to end life and being seen by mental health provider. 4. Resident #5?s preliminary ISP with review date 4-21-22 documented resident incontinent of bladder less than weekly with pad inserted in underwear. The UAI dated 4-8-22 did not document this need. Resident?s need for stairclimbing assessed as mechanical help/ physical assistance; the ISP documented the need as not performed- resident lives on the first floor. 5. Resident #6?s UAI dated 10-2-21 documented transferring as mechanical help/supervision. The ISP dated 10-21-21 documented mechanical help, use of walker. Wheeling/mobility need documented on ISP as resident able to propel self short distance, resident also required physical assistance from staff to push wheelchair.
Plan of Correction:	1. The Director of Nursing/ designee reviewed and corrected the UAI?s and ISP?s as appropriate for resident #3, resident #4, resident #5, and resident #6 to accurately reflect and identify the current needs of the residents. 2. Resident Coordinator will be re-educated to ensure that all resident?s UAI?s and ISP?s correspond and correctly identify and document the care needs of residents simultaneously. 3. The Director of Nursing/designee will conduct a weekly audit resident?s UAI?s and ISP?s to ensure that all UAI?s and ISP?s accurately reflect resident?s needs. Audit results will be reviewed for patterns and trends and findings reported to the leadership team.
Standard #:	22VAC40-73-450-D
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). Evidence 1. Resident #5?s record document resident receives services from a hospice organization beginning 4-21-11. The ISP did not include who, when, what and where services were provided. 2. Staff #1 acknowledged the aforementioned resident?s ISP did not documented what services where provided by the hospice agency.
Plan of Correction:	1. Resident #5?s hospice services were added to ISP. Resident #5 is the only resident receiving hospice services in the facility at this time. 2. Staff members involved in updating and reviewing ISP?s will be re-educated on accurately documenting hospice services on resident?s ISP?s to include the who, what, when and where of services provided. 3. The record and ISP of any residents who receive hospice services will be audited for accuracy by the Director of Nursing/ designee and findings reported to the leadership team.
Standard #:	22VAC40-73-450-E
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or designee, and the by the resident or legal representative for two of six residents? records. Evidence: 1. Resident #1?s individualized service plan (ISP) with an end date/review date of 8- 29-22 was not signed and date by the resident or resident?s legal representative. 2. Resident #3?s ISP dated 10-8-21 (review date 10-8-22) was not signed by the resident or resident?s legal representative. 3. Staff #1 acknowledged the aforementioned residents? ISPs were not signed and dated.
Plan of Correction:	1. Resident #1 and resident #3?s ISP?s have been signed and dated by the residents/ resident?s legal representatives. 2. ISP?s have been audited to ensure the ISP was signed and dated by the licensee, administrator, or designee, administrator or dis residents/ resident?s legal representative?s signatures are in place and dated. Resident coordinator will be re-educated to ensure they understand the signature requirements for the ISP. 3. The Director of Nursing/designee will conduct audit the UAI?s monthly for 3 months to ensure they contain the required signatures. Audit results will be reviewed for patterns and trends and findings reported to the leadership team.
Standard #:	22VAC40-73-470-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure either directly or indirectly, that the health care service needs of residents are met. Evidence: 1. On 5-10-22 resident #2?s record included a physician?s order dated 3-10-22 for physical therapy for strengthening- mobility endurance. 2. Staff #1 acknowledged the resident?s therapy order was not completed.
Plan of Correction:	1.Resident #2?s record was updated to show the physical therapy order was discontinued per resident?s refusal. 2. Nursing staff will be educated on ensuring that therapy orders are initiated and/or discontinued as appropriate and properly documented in their record once therapy is completed. 3. Director of Nursing/ designee will perform weekly audits to review and ensure physical therapy orders are correctly documented in resident?s physician orders. Audit results will be reviewed for patterns and trends and findings reported to the leadership team.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and staff interviewed, the facility failed to ensure medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility for two of three medication pass observation. Evidence: 1. Resident #1?s Milk of Magnesia was not available as noted on resident?s May 2022 medication administration record (MAR). 2. Resident #3?s Milk of Magnesia, Tylenol, Enema and Throat spray were not available as noted on resident?s May 2022 MAR. 3. Staff #5 acknowledged the aforementioned PRN medications were not available on 5-10-22 following medication pass observation.
Plan of Correction:	1. Resident #1 and Resident #5?s PRN medications were immediately ordered, and are currently available for residents. 2. Resident care coordinator, nurses, and RMA?s will be re-educated on ensuring all resident?s medications to include PRN (as needed) medications are available, properly labeled for the specific resident and properly stored. A full medication cart audit was completed to ensure all residents have all medications available per physician?s orders. 3. The resident coordinator/designee will monitor medication carts to ensure all resident?s routine and non-routine medications are available.
Standard #:	22VAC40-73-700-2
Description:	Based on observation, document reviewed and staff interviewed, the facility failed to ensure it posted a ?No Smoking Oxygen in Use? signs and enforce the smoking prohibition in any room of a building where oxygen is in use. Evidence: 1. On 5-10-22, resident #5?s record documented PRN use of oxygen at 2L via nasal cannula. The no smoking sign was not posted on the resident?s room door. 2. Staff #1 acknowledged the facility did not post the no smoking sign on the aforementioned resident?s door as required.
Plan of Correction:	1. Resident #5?s oxygen order was discontinued per physician?s orders. All other residents with physicians? orders for oxygen have the ?No Smoking, Oxygen in Use? signs in place by their front doors. 2. Nursing staff will be re-educated about ensuring it posts a ?No Smoking, Oxygen in Use? signs and enforce the smoking prohibition in any room of a building where oxygen is in use. 3. Manager/ designee will conduct weekly audits for 6 weeks to ensure that ?No Smoking, Oxygen in Use? signs are posted as appropriate.
Standard #:	22VAC40-73-860-G
Description:	Based on observation and staff interviewed, the facility failed to ensure the hot water at taps available to residents was maintained within a range of 105 degrees Fahrenheit (F). to 120 degrees F. Evidence: 1. On 5-10-22 during a tour of the facility with staff #10, the water temperature in room #105 at 9:15 a.m. was 122.4 degrees F. 2. Staff #2 and #10 acknowledged the water temperature did not meet the required temperature range.
Plan of Correction:	1. The assisted living manager immediately corrected the water temperature in resident room #105 on 5/10/22. 2. Assisted living manager audited all apartments and common area taps available to residents to ensure temperatures in range of 105 to 120 degrees Fahrenheit. Environmental staff will be re-educated on temperature range for all taps 3. The Manager/ designee will conduct audits of water temperature checks in resident room and resident accessible areas at least twice monthly for 3 months. Audit results will be reviewed for patterns and trends and findings reported to the leadership team.
Standard #:	22VAC40-73-960-B
Description:	Based on observation and staff interviewed, the facility failed to ensure the fire and emergency evacuation drawing posted included all of the required information. Evidence: 1. On 5-10-22 during a tour of the facility with staff #2, emergency evacuation posting on the third floor did not include primary and secondary route and telephone locations. 2. Staff #2 acknowledged the evacuation posting did not include all required information.
Plan of Correction:	1. Emergency evacuation posting on the third floor was immediately updated to include primary and secondary routes and telephone locations. 2. The Management team was educated on the required information and the meaning for each posted fire and emergency evaluation drawing. 3. Administrator/designee will audit postings monthly for three months to ensure completeness of required information on all emergency evacuation postings.
Standard #:	22VAC40-73-970-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the fire and emergency evacuation drill frequency and participation was conducted in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13 VAC 5-51). The drills required for each shift in a quarter shall not be conducted in the same month. Evidence: 1. On 5-10-22, the fire drill report documented the following drills date and time: 1-15-22 (11:00 a.m.); 2-7-22 (11:00 p.m.); 3-4-22 (7:30 p.m.); 4-7-22 (9:00 a.m.) and 5-9-22 (1:00 p.m.). 2. Staff #1 acknowledged the fire drills were not conducted per shift as required.
Plan of Correction:	1. 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 specified order of 1,2,3 in a quarter. 2. The Manager/designee will be educated on the importance of conducting drills in accordance with the regulation. Calendar reminders were created for each month as a reminder of which shift the fire drill should be conducted on each month. 3. The Administrator/designee will conduct audits of all exercises performed to ensure the drills are conducted as required for each shift in a quarter. The Administrator/designee will report any trends to the leadership team.
Standard #:	22VAC40-73-980-A
Description:	Based on observation and staff interviewed, the facility failed to ensure a complete first aid kit was on hand in each building at the facility, located in a designated place that is easily accessible to staff and not the residents. Items with expiration dates must not have dates that have already passed. The kit shall include all required items per area of standard. Evidence: 1. On 5-10-22 a check of the facility?s first aid kit for the building was conducted with staff #2. The hand sanitizer was dated 3-2020, the adhesive tape and antiseptic (ointment) were not included in the kit. 2. Staff #2 acknowledged the first aid kit for the facility did not include all required items.
Plan of Correction:	1. The facility?s first aid kit was immediately updated with the missing/expired items to include hand sanitizer, adhesive tape and antiseptic ointment. 2. Resident coordinator performed a full audit of both first aid kits and complete a monthly checklist of each first aid kits to ensure all necessary supplies are available and that all items are not expired. 3. Manager/designee will ensure the First Aid Checklist is completed monthly for 3 months