VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise Assisted Living at Fair Oaks
3750 Joseph Siewick Drive
Fairfax, VA 22033
(703) 264-0506

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Feb. 5, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 63.2 Licensure and Registration Procedures

Comments:

On 2/4/2020 Licensing Inspector (LI) initiated an unannounced inspection in response to a self-reported incident. LI reviewed the resident record and conducted staff interviews with another government agency. On 2/13/2020 an additional staff and resident interview was conducted. On 2/19/2020 the Violation Notice was issued and the assessed risk assigned to violations was reviewed during the exit interview. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps 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 and if you have any questions please call 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-40-A
Description:	Facility failed to ensure that the licensee shall ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures. Evidence: Based on interview Resident #1 was receiving care including but not limited to bathing, dressing, transferring and feeding from a resident companion/private duty aide. The facility Resident Companion Policy #CL-0003 indicates that Resident Companions will not provide care and are retained for the purposes of providing non-clinical observation and/or keeping a resident company.
Plan of Correction:	A. With respect to the specific resident/situation cited: The ALC updated the ISP for resident #1 to reflect the companion services provided by companion(s). Resident no longer resides at the community. The ED or designee initiated training on 1/17, and continues the process of conducting refresher training with the care team regarding the limited services that companions may provide; and care team member responsibilities for reporting companions that are providing ADL assistance, dining assistance, transfer or mobility assistance, or any care beyond keeping a resident company, to the ED or a Coordinator/Director. The ALC called the resident?s responsible party to review the companion policy. Executive Director emailed correspondence to residents/responsible parties reviewing the Companion policy, followed by a phone call to confirm their understanding and compliance. C. With respect to what systemic measures have been put into place to address the stated concern: The RC and ALC have audited and updated ISPs for residents with companion services to reflect the limited companion services being provided. Issues identified were addressed and resolved. The RC, ALC and/or designee will review ISPs for residents with companion services weekly for 3 months to confirm that companion services and the schedule/ coverage is listed The RC and/or ALC will present the results of the reviews to the Quality Assurance and Performance Improvement (QAPI) committee for the next 3 months During and at the end of the 3 month period, the QAPI committee will evaluate the results of the audit and determine if additional focus or action is warranted. D. With respect to how the plan of correction will be monitored. The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director (ED), Assisted Living Coordinator (ALC) and Reminiscence Coordinator (RC) met with the companions of current residents to review the policy regarding not providing ADL assistance, dining assistance, transfer or mobility assistance, or any care beyond keeping a resident company; and to discuss and clarify the limited services that meet the companion definition. The companions expressed an understanding of their limited role.
Standard #:	22VAC40-73-70-F
Description:	Facility failed to ensure that there is documentation in the resident's record as required by 22VAC40-73-470 F. Evidence: An incident report and communication log entry was created regarding Resident #1's injuries on 1/16/2020. There is no documentation in the resident's progress notes regarding the circumstances surrounding the injury or the response to the injury.
Plan of Correction:	A. With respect to the specific resident/situation cited: A transfer note for Resident #1 was documented in the resident record by the Nurse. Resident #1 no longer resides at the community. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: ED or designee will review events that occurred in the past 30 days to confirm that progress notes were completed. Issues that may be identified will be addressed and refresher training initiated as needed. C. With respect to what systemic measures have been put into place to address the stated concern: During the morning meeting the ED, ALC, RC and /or RCD will review resident events from the previous day to confirm timely and complete progress notes were entered into the resident record for 3 months. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The ED and/or designee will review the progress notes of resident events weekly for an additional 2 months to confirm timely and complete progress notes are entered into the resident record. The ED will present the results to the QAPI committee for the next 3 months. During and at the end of the 3 month period, the QAPI committee will evaluate the results and determine if additional focus or action is warranted. D. With respect to how the plan of correction will be monitored. The Executive Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-220-A
Description:	Facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the direct care or companion services provided by private duty personnel to meet identified needs shall be reflected on the resident's Individualized Service Plan (ISP) and that documentation of resident care required by this chapter is maintained. Evidence: Staff interviews verified that the companion was providing care to Resident #1 however Resident #1's most recent ISP dated 1/6/2020 does not include the specific services of the resident companion and there is no documentation regarding the services that were provided by the resident companion.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #1 no longer resides at the community. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The ALC and RC reviewed current residents? Individualized Service Plans (ISPs) to confirm that they reflect the name, schedule of the companion and services rendered. No issues were identified. C. With respect to what systemic measures have been put into place to address the stated concern: The ALC and RC will review current residents? Individualized Service Plans (ISPs) to confirm that they reflect the name, schedule of the companion and services rendered, weekly for 3 months.The ALC or RC will present the results to the QAPI committee for the next 3 months. During and at the end of the 3 month period, the QAPI committee will evaluate the results and determine if additional focus or action is warranted. Resident companions began going through an orientation process conducted by the BOC, ALC, RC, or designee to confirm their understanding regarding not providing ADL assistance, dining assistance, transfer or mobility assistance, or any care beyond keeping a resident company; and to discuss and clarify the limited services that meet the companion definition. The ED or designee will discuss the companion policy during the move in process with residents and/or responsible parties. D. With respect to how the plan of correction will be monitored. The Executive Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-450-C
Description:	Facility failed to ensure that the comprehensive Individualized Service Plan (ISP) shall be completed within 30 days after admission and shall include a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them. Evidence: Based on interview and documentation review Resident #1's most recent ISP dated 1/06/2020 does not include the resident's assessed need for crushed medications, an adjustable bed to be lowered to prevent falls and routinely taking meals in her room.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #1 no longer resides at the community. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: ALC and RC conducted an audit of current residents? ISPs to confirm that special orders regarding crushed medications, adjustable beds, and in-rooms meals and dining preferences are reflected on the ISP. Issues identified were addressed and resolved.C. With respect to what systemic measures have been put into place to address the stated concern: The ALC and RC will conduct monthly audits for 3 months to confirm that special orders regarding crushed medications, adjustable beds, and in-rooms meals and dining preferences are reflected on the ISPs. The ED will present the results to the QAPI committee for the next 3 months. During and at the end of the 3 month period, the QAPI committee will evaluate the results and determine if additional focus or action is warranted. D. With respect to how the plan of correction will be monitored. The Executive Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-470-F
Description:	Facility failed to ensure that when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. The circumstances involved and the medical attention received or refused shall be documented in the resident's record. The date and time of occurrence, as well as the personnel involved shall be included in the documentation. Evidence: Based on interview and documentation review Resident #1 was observed with a serious injury between 6p - 7p on 1/16/2020 however medical attention was not provided until the morning of 1/17/2020 when EMS was activated.
Plan of Correction:	A. With respect to the specific resident/situation cited: First aid was rendered on 1/16/2020 by the Lead Med Tech. Resident #1 was transported to the hospital. Resident #1 no longer resides at the community. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: Skin evaluations were conducted by the licensed nurses and the care coordinators for current residents. No issues were identified.The ED, RCD, ALC, and RC conducted refresher training for care givers about the importance of reporting and escalating resident concerns or changes in condition to the ED or Coordinator/Director either in person or by phone and the timeline for doing so.ED or designee is reviewing events that occurred in the past 30 days to confirm that progress notes were completed. Issues that may be identified will be addressed and refresher training initiated as needed. The ED or designee has conducted an audit of events that occurred in the past 30 days to confirm timely reporting and obtaining of medical attention. Identified concerns were addressed. C. With respect to what systemic measures have been put into place to address the stated concern: The ED, ALC, RC, and / or Resident Care Director (RCD) will review new events during the morning leadership meetings to confirm that timely and prompt medical treatment was obtained and that the ED or Coordinator/Director were contacted, as needed. During the morning meeting the ED, ALC, RC and /or RCD will review resident events from the previous day to confirm timely and complete progress notes were entered into the resident record for 3 months. The ED and/or designee will review Resident events weekly for 3 months to confirm timely reporting, prompt medical treatment, and escalation of resident concerns and / or changes in condition to the ED or Coordinator/Director, as needed. The ED will present the results of the event reviews to the QAPI committee for the next 3 months. During and at the end of the 3 month period, the QAPI committee will evaluate the results and determine if additional focus or action is warranted. D. With respect to how the plan of correction will be monitored. The Executive Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	63.2-1706-A
Description:	Facility failed to ensure that licensees shall at all times afford the Commissioner reasonable opportunity to inspect all of their facilities, books and records, and to interview their agents and employees and any person living or participating in such facilities, or under their custody, control, direction or supervision. Evidence: Based on interview the facility refused to allow the Commissioner's representative to inspect documents pertinent to the internal investigation regarding resident injuries and the follow up related to this incident.
Plan of Correction:	A. With respect to the specific resident/situation cited: The ED and community leadership team have reviewed the regulations and confirmed their understanding of Commissioner access and inspection of their facilities, books, and records. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The ED and the community leadership team will provide Commissioner representatives access and inspection of their facilities, books, and records, to the extent required. C. With respect to what systemic measures have been put into place to address the stated concern: The ED and community leadership team will review the regulations on 2/24/20 and confirm their understanding of Commissioner access and inspection of their facilities, books, and records, and then monthly for 2 months. The ED will review the regulations with new Coordinators/Directors during their orientation process. The ED will present the results of the regulations review to the QAPI committee for the next 2 months. During and at the end of the 3 month period, the QAPI committee will evaluate the results and determine if additional focus or action is warranted. D. With respect to how the plan of correction will be monitored. The Executive Director is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.