22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS
Comments:
Type of inspection: Monitoring An on-site mandated monitoring was conducted on 8-19-24 (Ar 11:25 a.m./Dep 15:45 p.m.) The director was present and 23 participants on site upon arrival.
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Number of participants present at the facility at the beginning of the inspection: 23 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with participants: 1 Number of interviews conducted with staff: 4 Observations by licensing inspector: lunch meal observed, activity observed (word games conducted on patio), water temperature, first aid kit Additional Comments/Discussion: Facility responded to periodic facility outage during visit.
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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Based on record reviewed and staff interviewed, the facility failed to ensure the plan of care for a participant included all assessed needs.
Evidence: 1. On 8-19-24, participant #2?s assessment dated 7-2-24 documented need for help ambulatory ability. Walking need assessed as help needed when tired or long distance. Climbing stairs assessed as guidance and supervision help need. Toileting assessed as no help needed, however, the assessment noted reminders and cueing and assistance getting to bathroom, may need help turning the water off. These assessed needs were not documented on the participants Plan of Care dated 7-2-24. 2. Participant #3?s assessment dated 4-23-24 documented need for help for ambulatory ability. Walking need assessed as help needed when tired or long distance. Climbing stairs assessed as guidance and supervision help need. Activities of daily living (adl) needs assessed as help needed for toileting, reminders and cues and change if incontinent. Bowel and bladder assessed as need for help, reminders and cueing. Transferring assessed as need help getting up at times. These assessed needs were not documented on the participant?s plan of care dated 4-23-24. 3. Staff #1 acknowledged; the participants assessed needs noted on the assessment document was not documented on the plan of care documents.
Plan of Correction:
The two participant records have been corrected ? with revised Care Plans. In addition, all participant records will have an internal audit and new assessments and/or care plans will be developed as needed, within 90 days. (by 11-21-24)
Standard #:
22VAC40-61-260-B
Description:
Based on document reviewed and staff interviewed, the facility failed to ensure the assessment for tuberculosis (TB) in a communicable form was obtained no earlier than 30 days before admission.
Evidence: 1. On 8-19-24, the TB document in participant #2?s record did not include the date of the assessment. The participant?s record noted date of admit 7-2-24. 2. Staff #1 acknowledged the aforementioned participant?s TB document in the record did not have a date the assessment was completed.
Plan of Correction:
Corrected. This TB assessment was sent to the Dr. and the Doctor faxed back the date on the assessment for 6-10-24. We confirmed that the date he meant to sign it was 6-10-24. ( Nurse ) confirmed and re-sent the fax on 8-21-24 and again on 8-26-24. Date of Correction: 8-26-24.
Standard #:
22VAC40-61-300-C
Description:
Based on documents reviewed and staff interviewed, the facility failed to ensure it had written or verbal authorization from the physician or prescriber, or the physician?s authorized agent for prescription and nonprescription medications. Verbal orders shall be reviewed and signed by the physician or prescriber within 10 working days.
Evidence: 1. On 8-19-24, a medication pass observation was conducted with staff #4, who administered medications to participants #4 and #5. Following the administration, the request to see the physician?s order was made. Participant #4?s record did not have documentation of the physician's order for the Hydrocortisone 5 mg tablet administered. Staff #4 reviewed the facility?s electronic system, Netsmart- My Unit for a physician?s order. Staff also reviewed, the medication book which included copies of physician?s orders. The signed and dated physician's order was not located. A search for the physician?s order was also conducted by staff #1, #2 and #3, including contacting the participant?s representative. 2. Staff #1 acknowledged the aforementioned participant?s record did not have a signed prescriber?s order for Hydrocortisone 5 mg tablet prescribed on 6-18-24 per the document provided by staff # 2.
Plan of Correction:
Corrected. Signature was obtained on 8-20-24- participant?s medication order now has the signature.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
Find this content at:
http://www.dss.virginia.gov/facility/search/adc.cgi