22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION
Comments:
Type of inspection: Complaint An on-site complaint inspection was conducted on 7-2-24 by two inspectors from the Peninsula Licensing Office (Ar 09:43/Dep 15:30 p). The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6-20-24 regarding allegations in the resident care and related services.
Number of residents present at the facility at the beginning of the inspection: 19 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 (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 individualized service plan included assessed needs.
Evidence: 1. On 7-2-24 during a complaint inspection, resident #1?s uniformed assessment instrument (UAI) dated 6-12-24 noted transferring need assessed as physical assistance; the individualized service plan (ISP) dated 6-19-24 noted transferring completed by the resident (self/supervision) with occasional assist of 1 to 2 team members. Wheeling and Stairclimbing assessed as not performed; the ISP did not note who and what services would be provided. 2. Resident #2?s UAI dated 3-6-24 noted bathing and transferring need assessed as physical assistance; the ISP dated 4-23-24 noted bathing with 1 staff assistance and use of handrails and shower chair. Transferring noted as mechanical help, use of grab-bar. Wheeling and stairclimbing assessed as no help; the ISP noted not performed, no note indicating who, when and where services would be performed. Walking and mobility assessed as no help needed; the ISP noted walking with mechanical help/handrail as needed. Mobility noted mechanical help/supervision- handrails and staff supervision. 3. Staff # 1 acknowledged the residents? assessed needs and ISP did not agree.
Plan of Correction:
Resident Care Coordinator and Regional Director of Care will complete an audit of all current resident records to ensure that all resident UAI's match their ISP's. Audit will be completed by August 30, 2024. Going forward Executive Director will review all ISP's for compliance after being completed by the Resident Care Cordinator
Standard #:
22VAC40-73-680-C
Complaint related:
Yes
Description:
Based on record reviewed, document reviewed, and staff interviewed, the facility failed to ensure medication was not administered earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence: 1. On 7-2-24 during a medication complaint inspection, resident #1?s Controlled Drug Record noted resident?s Lorazepam 1 mg was administered at 10 p on 6-2-24. The resident?s scheduled dosage hour was 12:00 a.m. 2. Staff #3 acknowledged, administering the resident?s medication was given more than one hour prior to the scheduled dosing time.
Plan of Correction:
All medication staff will be inserviced on proper medication administration policies, six rights of medication administration, and standards on medication pass times and documentation. Medication staff inservices will be completed by the Executive Director by August 30, 2024.
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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