Inspection dates
11/29/2022
Areas reviewed
22VAC40-73 GENERAL PROVISIONS22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES22VAC40-73 PERSONNEL22VAC40-73 STAFFING AND SUPERVISION22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS22VAC40-73 RESIDENT CARE AND RELATED SERVICES22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS22VAC40-73 BUILDINGS AND GROUND22VAC40-73 EMERGENCY PREPAREDNESS22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTSARTICLE 1 – SUBJECTIVITY32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS63.2 GENERAL PROVISIONS63.2 PROTECTION OF ADULTS AND REPORTING63.2 LICENSURE AND REGISTRATION PROCEDURES63.2 FACILITIES AND PROGRAMS22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT22VAC40-80 THE LICENSE22VAC40-80 THE LICENSING PROCESS22VAC40-80 COMPLAINT INVESTIGATION22VAC40-80 SANCTIONS
Comments
Violations
22VAC40-73-320-A
Based on a review of resident records the facility failed to ensure that residents admitted to the facility do not have any of the conditions or care needs prohibited by 22VAC40-73-310.H
Evidence
- The admission physical examination for resident #6 dated 5/19/2021 states “needs continuous licensed nursing care” which is a prohibited condition.
Plan of correction
Household Leader is responsible for reviewing completed History & Physical forms to ensure potential residents are in fact appropriate for an assisted living level of care. If prohibited conditions are present, the physician will be contacted.
22VAC40-73-320-A
Based on a review of resident records the facility failed to ensure that a risk assessment documenting the absence of tuberculosis in a communicable form was obtained 30 days prior to admission.
Evidence
- Resident #6 was admitted to the facility on 5/14/2021. The tuberculosis risk assessment is dated 5/15/2021. Resident # 3 was admitted to the facility on 3/21/2022. The tuberculosis risk assessment is dated 3/22/2022.
Plan of correction
Once a History & Physical form (that includes a tuberculosis screening) is given to the Household Leader, they will ensure the tuberculosis form has been completed and signed by an appropriate party. This applies to both individuals moving from outside of the community and those moving from a different level of care.
22VAC40-73-320-A
Based on a review of resident records the facility failed to ensure that physical examinations were obtained 30 days prior to admission.
Evidence
- Resident #6 has an admission physical examination dated 5/19/2021.The date of admission to the facility is 5/14/2021.
Plan of correction
Household Leader is responsible for ensuring individuals in the process of moving into the community have a copy of the History & Physical form and understand the 30-day prior policy. This applies to both individuals moving from outside of the community and those moving from a different level of care. All History & Physical forms will be scanned into resident charts within a timely manner to reflect compliance.
22VAC40-73-1100-A
Based on a review of resident records the facility failed to ensure approval by the POA or legal representative prior to placement in the secure unit.
Evidence
- Resident #6 was admitted to the memory care unit on 5/14/2021 but the approval for placement in the secure unit for resident #6 was not signed until 9/14/2021
Plan of correction
Household Leader is responsible for meeting with the resident and/or POA on the day of admission to complete a secure unit consent form with the understanding that the resident will live in a secure household. All consents will be scanned into resident charts within a timely manner to reflect compliance. Secure unit reviews will be conducted on a biannual basis to confirm the level of care remains appropriate.
22VAC40-73-1090-A
Based on a review of resident records the facility failed to ensure that residents have been assessed as having a serious cognitive impairment prior to placement in a secure environment.
Evidence
- There is no assessment present and maintained in the resident record to support placement in the memory care unit for resident #5. The resident has an admission date of 8/30/2021. It is unclear when the resident was placed in the secure unit. There is an approval for placement form dated 12/9/2021and an ISP dated 12/22/2021.
Plan of correction
Household Leader will ensure that Serious Cognitive Impairment forms are included in a packet alongside the History & Physical and TB Screening for the appropriate physician to complete within 30 days prior to admission. All consents will be scanned into resident charts within a timely manner to reflect compliance.
22VAC40-73-320-B
Based on a review of resident records the facility failed to obtain an annual risk assessment for tuberculosis for all residents.
Evidence
- The last tuberculosis risk assessment for resident #4 is dated 8/27/2021; 9/8/2021 for resident #6 and 5/15/21 for resident #3.
Plan of correction
Clinical leader in tandem with the community nurse practitioner audited all residents’ annual TB screenings. Relevant screeningswere updated using the new DSS approved form.