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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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
Technical Assistance:
Written Assurance Personal Data
Comments:
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 07/16/24 at 8:14 am to 4:18 pm and 07/18/24 at 9:12 am to 4:47 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: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 10 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 4
Observations by licensing inspector: Breakfast and lunch were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and the call bell system was monitored.
Additional Comments/Discussion: None
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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review the facility failed to ensure within the 30 days preceding admission, a person shall have a physical examination completed by an independent physician.
Evidence: 1. The admission?s record for resident #8, admission date 07/17/24, contains a physical examination that documents an exam date of 05/10/24, however 05/10/24 is more than 30 days prior to the resident?s admission to the facility.
Plan of Correction:
The history and physical examination for resident 8 was amended by the attending physician in order to reflect the correct examination date. All other history and physical examination forms will be audited to verify they include an examination date that is not more than 30 days prior to the resident?s admission to the community. All new history and physical examination forms will be reviewed by the HCD and/or ED or designee to assure compliance with dating of history and physical exam forms. . The HCD is responsible for ongoing compliance. Will be reviewed in QAPI through 12.31.24 to monitor ongoing compliance.
Standard #:
22VAC40-73-440-A
Description:
Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident?s condition.
Evidence: 1. The record for resident #3, admission date 06/28/24, contains an UAI that documents an assessment date of 07/02/24 and is signed and dated by the assessor on 07/08/24. During an interview with resident #3, resident #3 confirmed their admission date to the facility as 06/28/24. 2. The record for resident #7 contains a hospice care note that documents the resident was admitted to hospice care effective 04/08/24. The UAI in the resident?s record is dated 01/19/24. The resident?s record does not contain a UAI completed when there was a significant change in the resident?s condition to include hospice care treatment.
Plan of Correction:
1. Resident #3 UAI will be updated to reflect correct assessment date and current status. Date to be corrected 09.15.24
2. Team members trained to complete the UAI will complete resident?s care and related documentation to monitor for changes that required updates to the UAI/ISP.
3. The Health Care Director or designee will review UAIs and ISPs for accuracy during the Quarterly Clinical Oversight and on an as needed basis. Findings will be reviewed in the Quality Assurance and Performance Improvement meetings.
4. Will be reviewed in QAPI through 12.31.24 to monitor ongoing compliance
Standard #:
22VAC40-73-450-A
Description:
Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed to address the basic needs of the resident that adequately protects his health, safety, and welfare. Exception: A Preliminary plan of care is not necessary if a comprehensive individualized service plan (ISP) is developed, in conformance with this section, on the day of admission.
Evidence: 1. The record for resident #3, admission date of 6/28/24, does not contain a preliminary plan of care completed on or within 7 days of admission or an ISP completed on the day of admission. During an interview with resident #3, resident #3 confirmed their admission date to the facility as 06/28/24.
Plan of Correction:
Resident Files will be Audited for compliance. Audit will be completed by 09.15.24 The Health Care Director or designee will conduct and complete the preliminary ISP no later than day of admission for all new move-ins. The ED or designee will review the preliminary ISPs for all new move-ins through December 31, 2024 to monitor for ongoing compliance.
Standard #:
22VAC40-73-450-D
Description:
Based on the record review 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 in the ISP.
Evidence: 1. The record for resident #7 contains a hospice care effective date of 04/08/24. The resident?s ISP dated 02/19/24 was not updated and reviewed to include hospice care services provided by the hospice care provider.
Plan of Correction:
The Community will correct the ISP to include detailed services provided by outside care partners for resident #7. The HCD or designee will review all hospice residents? ISPs to ensure that services by outside health care partners is included. ISP audit will be completed by 09.15.24. The HCD or designee will continue to monitor all ISP?s monthly. The HCD or designee will review the preliminary ISPs for all new move-ins through December 31, 2024 to monitor for ongoing compliance.
Standard #:
22VAC40-73-460-E
Description:
Based on the record review and staff interview the facility failed to ensure the facility shall regularly observe each resident for changes in physical, mental, emotional, and social functioning. Any notable change in a resident?s condition or functioning, including illness, injury, or altered behavior, and any corresponding action taken shall be documented in the resident?s record.
Evidence: 1. The facility?s communication log dated 07/11/24 for resident #3 states, ?fell in bathroom resident has skin tear.? The record for resident #3 and the facility?s communication log did not include documentation of corresponding action taken by the facility to provide first aide for the resident?s skin tears. 2. During an interview with staff #7, staff #7 acknowledged the facility staff applied a bandage and changed the bandage for the skin tear for resident #3, however the facility did not have documentation of the staff providing first aide to the resident?s skin tear. 3. The record for resident #3 contains physician orders dated 07/12/24 and 07/17/24 ?HHSN (Home Health Skilled Nursing) evaluation and treatment skin tears to right forearm,? however, the physician order dated 07/12/24 includes the wrong last name for the resident. Staff #7 confirmed the physician order dated 07/12/24 included the wrong last name for resident #3 which resulted in a delay of resident #3 receiving home health skilled nursing services for treatment of the skin tears. Staff #7 confirmed the record for resident #3 did not contain documentation of staff observing the resident?s skin tears and or the facility?s staff providing first aide to the skin tears.
Plan of Correction:
The HCD, and or/designee will partner with outside health care agencies to ensure all wound care and treatments outside of scope of practice is performed in accordance with physician's orders. All home health orders will be reviewed by HCD or designee by 09.15.24. The HCD or designee will review all new home health orders through December 31, 2024 to monitor for ongoing compliance.
Standard #:
22VAC40-73-480-C
Description:
Based on the record review the facility failed to ensure facilities shall arrange for specialized rehabilitative services by qualified personnel as needed by the resident. Rehabilitative services include physical therapy, occupational therapy, and speech language pathology services.
Evidence: 1. The record for resident #1 contains a physician order dated 09/26/23 for speech therapy ?ST eval & treat recurrent pneumonia.? The resident?s record did not contain documentation of completion of an evaluation and treatment for speech therapy. 2. During the onsite inspection, documentation of completion of a speech therapy evaluation and treatment for resident #1 was requested from staff #7 and was not provided.
Plan of Correction:
All charts will be reviewed to ensure compliance by 09.15.24. The Health Care Director or designee will meet with third party providers post treatment to obtain the required documents and care changes. The HCD or designee will review a minimum of 5 charts per month through December 31, 2024 to monitor for ongoing compliance.
Standard #:
22VAC40-73-660-A-1
Description:
Based on observation it was determined that the facility failed to ensure medications shall be stored in a manner consistent with current standards of practice and the storage area shall be locked.
Evidence: 1. During a tour of the facility on 07/18/24 at 9:22 am, the Licensing Inspector (LI) observed the medication cart located in the safe secure unit to be unlocked and unstaffed
Plan of Correction:
All LPN's and Medication Aides will be re-educated on standard procedures for securing the medication cart and promoting safety in medication administration before 09.15.24. The HCD or designee will reeducate as needed to all new staff through December 31, 2024 to monitor for ongoing compliance.
Standard #:
22VAC40-73-680-E
Description:
Based on the record review the facility failed to ensure medical procedures or treatments ordered by a physician or other prescriber shall be provided according to his instructions and documented. The documentation shall be maintained in the resident?s record.
Evidence: 1. The record for resident #2 contains a physician order dated 05/31/24 for ?Dermatology consult to eval & treat.? The resident?s record did not contain documentation of completion of a dermatology consultation and/or a dermatology evaluation and treatment. 2. During the onsite inspection, documentation of a dermatology consultation and evaluation and treatment for resident #2 was requested from staff #7 and was not provided.
Plan of Correction:
LPNs and RMAs will be re-educated before 09.15.24 on following physician orders per standard 22VAC40-73-(6)- 680-E and the community process and procedure for obtaining new orders. The HCD or designee will audit all new orders to ensure all consult(s) orders with physician completed as ordered. The HCD or designee will educate all LPN?s and RMA?s to complete new order process through December through December 31, 2024 to monitor for ongoing compliance.
Standard #:
22VAC40-73-860-I
Description:
Based on the onsite observation, the facility failed to ensure each facility shall store cleaning supplies and other hazardous materials in a locked area.
Evidence: 1. During the onsite observation on 07/18/24 at 9:18 am in the safe, secure unit, the Licensing Inspector (LI) observed Bleach and Comet, and cleaning liquid products located in the unlocked medication room. The medication room was unstaffed during the observation.
Plan of Correction:
Automatic door closers to be installed by EOD Friday August 9, 2024. Automatic door closers will be installed to automatically close behind the staff to ensure chemical storage areas remain closed and locked. Daily reviews of physical plant will occur to ensure hazardous materials are stored appropriately and all storage spaces are locked. Executive Director or designee will be responsible for daily physical plant review through December 31, 2024 to monitor for ongoing compliance.
Standard #:
22VAC40-73-870-I
Description:
Based on observation and staff interview the facility failed to ensure elevators, where used, shall be kept in good running condition and shall be inspected at least annually. Elevators shall be inspected in accordance with the Virginia Uniform Statewide Building Code (13VAC5-63). The signed and dated certificate of inspection issued by the local authority shall be evidence of such inspection.
Evidence: 1. The elevator?s certificate of inspection located in the facility, expired 05/31/24. Staff #8 confirmed the elevator?s certificate of inspection expired 05/31/24.
Plan of Correction:
The elevator inspection scheduled to be completed 08.12.24. Future inspections scheduled annually. Maintenance director or designee will be responsible to ensure inspection completed as scheduled through December 31, 2024 to monitor for ongoing compliance.
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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