VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Maple Lawn Residential Living
2526 Lee Jackson Highway
Staunton, VA 24401
(540) 337-2109

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: April 4, 2023 and April 5, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 GENERAL PROVISIONS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION

Technical Assistance:

1. Recommended auditing annual training hours at least every quarter to ensure staff complete the hours and subject matter as required (210.F and 330.A). 2. Ensure a mental health screening and progress notes are obtained and reviewed prior to admission on any resident with mental health impairments. Ensure the review of the information is clearly documented in the resident?s record. 3. Recommended placing a bright sign on the medication cart and on the wall in front of the cart to remind staff to clean hands with soap and water or hand sanitize before and after administering medications to each resident. 4. Recommended the administrator conduct medication administration record (MAR) audits at least monthly to ensure all information is complete and accurate on all MARs. 5. The drug reference book expires this year and must be replaced prior to January 2024. 6. Answered questions with the administrator and staff 2 about developing a form that includes all of the dietary review standards so the dietitian can check off each area, then sign and date the form and attach it to the summary report completed during each review. Agreed and recommended such a form be implemented. 7. Recommended maintaining a greater assortment of gauze pad sizes in the facility and vehicle first aid kits.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 4/4/2023 from approximately 6:50 am to 6:00 pm and on 4/5/2023 from approximately 8:45 am to 10:25 am and 1:05 pm to 3:30 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 15 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 + selected sections of 2 additional residents Number of staff records reviewed: 3 + selected sections of 2 contract staff Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 2 Observations by licensing inspector: Medication administration, activities, meals, first aid kits, staffing, postings, medication cart, etc. Additional Comments/Discussion: Once the fire official sends the inspection report, email it to this licensing inspector. An exit meeting will be conducted to review the inspection findings. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-A
Description:	Based upon observations and interviews, the facility failed to implement an infection control program regarding hand washing when administering medications. Evidence: 1. On 4/4/2023 at approximately 10:50 am, the licensing inspector (LI) observed staff 2 start to prepare medications for resident 8. As staff 2 prepared to open the medication package, the LI asked staff 2 if she had forgotten anything, she then immediately sanitized her hands. During the preparation, staff 2 did not wear disposable gloves or use hand sanitizer until prompted by the LI. The LI had to prompt staff 2 again when she started to open the medications for resident 9. 2. The facility?s infection control policy states on page 3, ?Staff and volunteers will clean their hands before and after resident care, as needed during the care of an individual, after gloves are removed, after using toilet facilities, immediately when the hands are accidentally contaminated with blood or body substances, and at other times as necessary.?
Plan of Correction:	A sign stating how to and how often to sanitize staff?s hands while dispersing medication was posted on the board at the med cart. Sanitizer dispersal station was placed on the cart instead of basket. Administrator and staff will be checking each other periodically to keep staff accountable for proper hand hygiene during medication administration, when serving meals, when providing resident care, when exiting a resident?s room and at all other times, as appropriate.
Standard #:	22VAC40-73-160-A
Description:	Based upon documentation and an interview, the facility failed to ensure the administrator completed at least six hours of training on residents with mental impairments. Evidence: 1. The training record for the administrator listed four hours of training addressing residents with mental impairments, 2. On 4/4/2023, the LI interviewed the administrator who stated the hours listed on her training record were the only hours she had completed on residents with mental impairments.
Plan of Correction:	The administrator notified VCU and signed up for 3 mental health related classes, while also acquiring information pertaining to more mental health classes provided by the oversight nurse. The administrator will check over the staff training records every 2 months, also check e-mail and VCU for any classes that are needed. The administrator will have 6 hours of mental health training completed by July 2023 and will ensure the required hours are completed annually.
Standard #:	22VAC40-73-330-A
Description:	Based upon a record review and interviews, the facility failed to ensure a mental health screening was completed and on file for one of six resident records reviewed. Evidence: 1. Resident 3 was admitted after an extensive hospital stay due to mental health issues. The resident record did not include a mental health screening or progress notes. 2. On 4/4/2023, the LI interviewed the administrator and staff 2 and both stated they did not have a mental health screening completed prior to resident 3?s admission and that a screening and progress notes were not on file. Neither staff could provide documentation as to attempts to obtain the required information or progress notes.
Plan of Correction:	For any new resident, a mental health screening determination form will be completed at time of interview prior to admission. The administrator and staff will double-check that the form is complete. If a mental health assessment is required, the administrator or designee will obtain the assessment prior to the resident?s admission. No resident will be admitted to the facility until all required paperwork is completed and at least 6 months of mental health progress reports are received. Individuals will be given 48 hours to get all paperwork in or facility will not be able to accept individual as a new admission.
Standard #:	22VAC40-73-510-B
Description:	Based upon record reviews and interviews, the facility failed to ensure appointments and communication were maintained between the facility and the mental health services provider for two of six resident records reviewed. Evidence: 1. The facility had a contract (signed 1/18/2023 by the facility administrator and the mental health provider) for all six residents reviewed, which stated, ?Progress report completed after each visit.? 2. The most recent individualized service plan (ISP) completed and signed 10/28/2022 for resident 2 stated, ?Sees a psychiatrist once every three months.? 3. Resident 2 met with the mental health services provider on 7/11/2022 and 1/9/2023, according to the progress reports that were faxed to the facility during this inspection. Reports/progress notes for these appointments were not on file at the facility until they were requested during this inspection. 4. The last progress report on file for resident 2 was dated as completed in February 2022. 5. The most recent individualized service plan (ISP) completed and signed 9/26/2022 for resident 5 stated, ?Sees a psychiatrist once every three months.? 6. The last progress report on file for resident 5 was dated as completed in April 2022. 7. On 4/4/2023, the LI interviewed the administrator and staff 2 and both stated resident 2 had appointments every six months and resident 5 had appointments every three months; however, both stated since the appointments were completed via teleconference and written reports had not been obtained of those sessions.
Plan of Correction:	Residents will communicate to mental health physician via telecommunication for their mental health progress appointments. Administrator and staff will inform the nurse and doctor to send mental health progress reports at the end of each session. If not received within 24-48 hours, staff will contact mental health provider for the reports and schedule a pickup time. Administrator will have daily meetings with staff to review the situation to certify that the progress reports were received within the time frame. On day of mental health appointment, staff will contact mental health provider/nurse or resident?s physician to see if there were any changes pertaining to the resident?s medication or pertaining to their appointment and scheduling of appointment in order to ensure information is updated and kept current in the resident?s ISP, medication administration record and file.
Standard #:	22VAC40-73-680-I
Description:	Based upon documentation and an interview, the facility failed to ensure the medication administration records (MARs) included all information required for two of six MARs reviewed. Evidence: 1. Resident 8 had physician?s orders signed on 3/1/2023 for Divalproex, Melatonin, Sertraline and Buspirone. 2. The March and April MARs for resident 8 did not include a diagnosis for four medications (Divalproex, Melatonin, Sertraline and Buspirone). 3. On 4/4/2023, the LI interviewed staff 2 who stated the diagnosis for each of these medications was not on the March or April MARs.
Plan of Correction:	The administrator will start conducting monthly audits on MARs and physicians? orders to verify that all required information, including the diagnosis, is listed on both. Staff will start highlighting the diagnosis on the MARs. If any of the information is missing, the physician (or the pharmacy, if appropriate) will be contacted regarding the missing information and the need to be corrected as soon as possible. The request for the missing information will also be logged in the communication logbook (that is kept in the medication cart) and in the pharmacy notebook. When the information is missing, the staff will have to hand write the missing information on the current MAR and list it for the pharmacy to be added on the resident?s new MAR for the following months.
Standard #:	22VAC40-73-970-A
Description:	Based upon documentation and an interview, the facility failed to ensure fire drills were conducted on each shift in each quarter. Evidence: 1. Based upon the fire drill log sheets, a fire drill was held during the first shift at 10:00 am on 10/5/2021. The next fire drill on first shift was not held again until 9:30 am on 4/15/2022. 2. On 4/4/2023, the LI interviewed staff 2 who stated, ?I must have gotten mixed up and held a drill on the wrong shift, which got me off track.?
Plan of Correction:	The administrator and staff will start marking and highlighting the calendar for the correct shift to be done for each month and it will be documented on the fire drill form. The administrator will review the fire drill forms each month in order to ensure fire drills are being held on the appropriate shift and to ensure compliance.