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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS
Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.
Comments:
A renewal inspection was initiated on October 25, 2021 and concluded on October 29, 2021. The executive director was contacted by telephone to initiate the inspection. The executive director reported that the current census was 61. The inspector emailed the executive director a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 4 resident records, 4 staff records, physician's orders, Medication Administration Records (MARs) and other facility documentation submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on October 29, 2021 which included a tour of the facility and the observance of resident rooms, facility postings, building and grounds, emergency food/water, and the medication cart. An exit interview was conducted with the executive director and resident care director on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.
Based on a review of resident records, the facility failed to report to the regional licensing office within 24 hours a major event that negatively affected or that threatened the life, health, safety, or welfare of a resident.
Evidence: Progress Notes dated 10-5-21 for Resident # 3 stated that resident "had a cat scan and it showed he has active inflammation pockets in his lungs that are destroying his lung tissue which is coming from him having COVID". The facility's executive director informed the licensing inspector during the inspection that the resident tested positive for COVID-19 on 9-21-21 and the facility reported it to the Health Department on 9-27-21. However, the facility failed to report the positive COVID case to the licensing inspector.
Plan of Correction:
1. Specific steps taken to correct non-compliance with the standard: a. Executive Director reported this situation to the licensing inspector during the renewal inspection.
2. Measures implemented to prevent non-compliance from occurring again: a. Community staff, as referenced below, will continue reporting future similar situations to the Health Department and now the licensing inspector as well.
3. Individuals responsible for implementing steps taken to correct non-compliance with the standard, measures taken to prevent non-compliance from occurring again, and monitoring preventative measures: a. Alicia Doyle, Assistant Care Director b. Rebecca Pierce, Resident Care Director c. Maureen Davis, Executive Director
Standard #:
22VAC40-73-580-A
Description:
Based on a review of facility documentation the facility failed to ensure that it obtained an annual inspection report from the Virginia Department of Health.
Evidence: The facility provided documentation of a health inspection report from the Virginia Department of Health last dated 1-30-2020.
Plan of Correction:
1. Specific steps taken to correct non-compliance with the standard: a. Virginia Department of Health conducted an annual inspection on November 1, 2021.
2. Measures implemented to prevent non-compliance from occurring again: a. The Virginia Department of Health suspended on-site inspections from March of 2020 to May of 2021 due to the COVID pandemic. Therefore, the Virginia Department of Health was not able to conduct an inspection during that time. Furthermore, due to the backlog of inspections created during this time the Virginia Department of Health was not able to inspect this community per the normal schedule. b. Moving forward, the Executive Chef or his designee will proactively contact the Virginia Department of Health to request an annual inspection. 3. Individuals responsible for implementing steps taken to correct non-compliance with the standard, measures taken to prevent non-compliance from occurring again, and monitoring preventative measures: a. Executive Chef, Tony Hughes b. Sous Chef, Justin Martin c. Maureen Davis, Executive Director
Standard #:
22VAC40-73-970-E
Description:
Based on a review of facility documentation the facility failed to document the participation of residents in fire and emergency drills.
Evidence: The facility documented the Number of Residents Participating as "0" on the Record of Required Fire and Emergency Evacuation drills for October 2020 through October 2021. The facility only provided documentation of signatures of residents participating in the Fire and Emergency Evacuation Drill dated 5-20-21.
Plan of Correction:
1. Specific steps taken to correct non-compliance with the standard: a. Community staff, as indicated below, will ensure monthly documentation of resident participation in fire and/or emergency drills.
2. Measures implemented to prevent non-compliance from occurring again: a. The Maintenance Director will document monthly resident participation in fire and/or emergency drills. b. The Maintenance Director will submit this documentation to the Executive Director for review monthly.
3. Individuals responsible for implementing steps taken to correct non-compliance with the standard, measures taken to prevent non-compliance from occurring again, and monitoring preventative measures: a. James Morris, Maintenance Director b. Maureen Davis, Executive Director
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.
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http://www.dss.virginia.gov/facility/search/alf.cgi