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
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: An unannounced monitoring inspection took place on 8/12/24 at 9:11 am to 3:10 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 08/07/2024 regarding allegations in the area of: Article 3: Safe, Secure Environment and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 86
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 5
Observations by licensing inspector: An observation of the safe secure environment was completed. Additional Comments/Discussion: None
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 the individualized service plan (ISP) shall include A description of identified needs based upon the UAI other sources.
Evidence: 1.The record for resident #1, admission date of 06/02/23 to the facility?s safe secure environment contains the following: an assessment for serious cognitive impairment dated 05/23/23 that documents ?a serious cognitive impairment due to dementia and the resident is unable to recognize danger or protect his/her own safety and welfare.? 2.Resident?s # 1 physician notes dated 09/04/23 and 06/27/24 documents a diagnosis of ?dementia? and includes the following: ?patient requires 24-hour supervision and assistance. Continue supportive care, maintain safety, and fall preventions.? 3.Resident?s #1 ISP dated 5/28/24 does not include an identified need to address the resident?s serious cognitive impairment to include dementia, placement in the safe secure environment, and needs for supervision. 4.Resident?s #1 UAI dated 5/28/24 documents the resident needs human help supervision with toileting. The resident?s needs for supervision with toileting is not included in the resident?s ISP dated 5/28/24.
Plan of Correction:
The HCD/HSD or designee will ensure that all residents are assessed face to face and a comprehensive ISP is developed to meet the resident's individualized care and service needs.
The ISP will be provided to the family for review. The family will be asked to sign and date the document following the review.
The Executive Director or designee will conduct a monthly audit of all new resident files to ensure they have a current UAI/ISP. Audits will be conducted for 4 months to monitor for compliance.
Standard #:
22VAC40-73-460-D
Description:
Based on the record review and staff interviews the facility failed to ensure the facility shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises.
Evidence: 1. Resident?s #1 incident report dated 8/07/24 documents the following incident that occurred on 08/07/24 in the safe secure environment: ?Resident had an unseen fall, unsure of the time of incident. When 7-3 staff came in, they seen resident in the bathroom on the floor lying in blood. Resident stated that she had been on the floor all night. Resident did suffer head trauma and bleeding. Resident sent to the Norfolk General hospital for evaluation and treatment.? 2. During an interview, staff #1 reported on the day of 08/07/24 approximately the time of 7:40 am, staff #1 found resident #1 lying on the floor in the resident?s bathroom. Staff #1 observed the following on resident #1: ?head and nose bleeding? ?dry blood on arm? ?resident #1 complained of shoulder pain? ?blood on ground and toilet chair.? 3. The record for resident #1 contains physician notes dated 09/04/23 and 06/27/24 that documents a diagnosis of ?dementia? and includes ?patient requires 24-hour supervision and assistance. Continue supportive care, maintain safety, and fall preventions.? 4. Resident?s #1 ISP dated 5/28/24 documents ?resident is at a moderate potential risk for falls.? 5. Resident?s #1 UAI dated 5/28/24 documents the resident needs human help supervision with toileting and bathing. 6. The facility?s staff schedule documents staff #2, #3, and #4 worked as the onsite direct care staff working in the safe secure environment for the 11pm to 7am shift on 8/06/24 to 8/07/24. 7. During an interview with staff #2, staff #2 confirmed that they did not observe resident #1 and did not complete round checks for resident #1 during the 11pm to 7am shift on 8/06/24 to 8/07/24. 8. During an interview with staff #3, staff #3 reported completing an observation on resident #1 once at 3:30 am on 8/07/24 during the 11pm to 7am shift and stated resident was sleeping, but staff #3 did not document this encounter. 9. During an interview with staff #4, staff #4 confirmed that they did not observe resident #1 and did not complete round checks for resident #1 during the 11pm to 7am shift on 8/06/24 to 8/07/24. 10. The facility?s round logs for the safe secure environment includes the following statement: ?8/6/2024, 08/07/2024, no rounds done.?
Plan of Correction:
Residents who cannot use the call bell system due to a physical or serious cognitive impairment were placed on a two-hour rounding log 08.12.24. The HCD/HSD will review the rounding log daily to ensure rounds are completed as scheduled. The HCD/HSD will ensure all that all resident UAIs and ISPs reflect the residents? physical or cognitive impairment and the need for regular rounding. The HCD/HSD will review 5 charts weekly to assure UAIs and ISPs reflect residents? assessed needs. Audits will continue for 4 months to monitor for 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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http://www.dss.virginia.gov/facility/search/alf.cgi