VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise at Mount Vernon
8033 Holland Road
Alexandria, VA 22306
(703) 780-9800

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Sept. 19, 2019 and Sept. 20, 2019

Complaint Related: No

Areas Reviewed:

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 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.

Comments:

An unannounced renewal inspection was initiated on 9/19/19 and completed on 9/20/19. At the time of entrance, 77 residents were in care. Meals, medication administration and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of 10 resident records and five staff records. Findings were discussed and an exit meeting was held. 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1100-C
Description:	Based on record review, the facility failed to ensure that the written approval for placement into the special care unit, is retained in the resident record. Evidence: Resident #6 was admitted to the special care unit in August 2019. The resident record did not contain the written approval from the resident, a relative, or a legal representative prior to the resident's admission into the special care unit.
Plan of Correction:	Resident #6?s written approval was obtained from the Power of Attorney (POA) and placed in the resident medical record. The Reminiscence Coordinator conducted an initial audit of current residents? admission documentation (written approval) of appropriateness of continued residence in the special care unit. Issues identified were addressed and resolved. The Resident Care Coordinator and/or Reminiscence Coordinator will conduct an audit of new residents to confirm written approval from the resident, a relative, or a legal representative prior to the resident's admission into the special care/secured neighborhood - monthly for 3 months. Issues identified will be addressed and resolved. The results of the audits will be presented to the QAPI committee. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the audits of the initial and annual review of appropriateness of continued residence and determine if additional focus or action is warranted. 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.
Standard #:	22VAC40-73-210-B
Description:	Based on record review, the facility failed to ensure that all direct care staff members attend at least 18 hours of annual training. EXCEPTION: Direct care staff who are licensed health care professionals or certified nurse aides shall attend at least 12 hours of annual training. Evidence: Staff #3 began working at the facility on 7/3/00. Facility records did not contain documentation that Staff #3 completed at least 12 hours of annual training, within the review period (7/3/18 - 7/3/19).
Plan of Correction:	Staff #3 was removed from the care schedule immediately, was scheduled for training and will not return on the care schedule until requirements are met. Training has been completed. The Business Office Coordinator (BOC), Assisted Living Coordinator and Reminiscence Coordinator conducted an audit of team member files to confirm annual training compliance. Issues identified were addressed and resolved. No issues were identified. Monthly Training Classes have been scheduled for the remainder of 2019 and 2020. The training that has been scheduled complies with VA requirements. Training participation information will be distributed to the Coordinators by the BOC so that they may follow-up with their team members and confirm compliance. Training compliance will be monitored and audited by the BOC and presented during QAPI meetings monthly for 3 months. During and at the end of the 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results and determine if additional focus or action is warranted. 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.
Standard #:	22VAC40-73-250-C
Description:	Based on record review, the facility failed to ensure that all of the required personal and social data is included in the staff record. Evidence: Completed orientation documentation was not found in the records of Staff #1 and Staff #4. The forms were included in the staff records, but the forms were not documented as being completed by the staff member or the trainer. Original criminal history record reports were not found, within 30 days of hire, in the records of: Staff #6 (hired 2/18/19), Staff #7 (hired 5/29/19), or Staff #8 (hired 5/27/19).
Plan of Correction:	Staff #1?s orientation was completed during the first week of hire based upon attendance records; however required documentation was not completed. Documentation was completed during inspection. Staff #4: team member is no longer employed at the community. Staff 6, 7, and 8?s records had completed national background checks; Staff 6, 7, and 8?s Virginia State Background Checks were completed, no concerns identified in the checks, and the documentation placed in their records 9/20/2019. The Business Office Coordinator (BOC), Assisted Living Coordinator and Reminiscence Coordinator audited current team member files to confirm orientation training within the first 7 days of hire including documentation of attendance and completion, prior to scheduling team members; and to confirm that Virginia State Backgrounds Checks were processed using the Virginia website, in conjunction with the National Background Checks; and there is supporting documentation in the team member files. Issues identified were addressed and resolved. No issues were identified. The Business Office Coordinator (BOC) and Executive Director will audit newly hired team member records - Orientation compliance and Virginia State Background Checks over the next 3 months to verify compliance and will present the results to the QAPI committee monthly for 3 months. During and at the end of the 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the audits and determine if additional focus or action is warranted 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.
Standard #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member submits the results of a risk assessment for tuberculosis, documenting the absence of tuberculosis in a communicable form. The risk assessment shall be provided on or within seven days prior to the first day of work and shall be no older than 30 days. Evidence: The chest x-ray for Staff #1, hired 5/18/19, was dated 8/31/18. The x-ray was more than 30 days old, when Staff #1 was hired. The record for Staff #4, hired 5/6/19, did not contain a risk assessment for tuberculosis.
Plan of Correction:	Staff #1 was sent to a medical provider to have tuberculosis risk assessment. Tuberculosis test negative. Staff #4 is no longer employed. The Business Office Coordinator (BOC) conducted an audit of team member files to confirm required TB tests and that TB screening assessments are updated and included in the personnel files. Issues found were identified and resolved. The Business Office Coordinator (BOC) will implement a tracking system to manage team member required TB tests, and TB screening/assessments, pre-hire and annually. The BOC will audit team member files monthly for 3 months to confirm required TB tests and TB screening assessments and present the findings to the QAPI committee. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the team member file audits and determine if additional focus or action is warranted. 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.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains certification in first aid. Each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. Evidence: First aid certification was not found in the records for: Staff #1 (hired 5/18/19), Staff #4 (hired 5/6/19), and Staff #5 (hired 5/6/19).
Plan of Correction:	Staff #1: CPR/First Aid certification was obtained 9/19/2019 and placed in the team member file. Staff #4: Is no longer an employee of Sunrise. Staff #5: CPR/First Aid Certification was obtained 9/19/2019 and placed in the team member file. The Business Office Coordinator (BOC) conducted an initial audit of team member files to confirm required CPR/First Aid is completed and Certifications included in the personnel files. Issues found were identified and resolved. The Business Office Coordinator (BOC) will implement a tracking system to manage team member required CPR/First Aid Certification pre-hire, annually and pending expiration. Routine scheduling of CPR/First Aid classes will be implemented by the Oct 15th to maintain compliance. The Business Office Coordinator (BOC) or designee will continue to conduct monthly audits of team member files for 3 months to confirm first aid certifications are active and there is supporting documentation in the personnel files. Issues identified will be addressed. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the team member first aid certification audits and determine if additional focus or action is warranted. 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.
Standard #:	22VAC40-73-320-B
Description:	Based on record review, the facility failed to ensure that each resident receives a risk assessment for tuberculosis annually. Evidence: The most recent tuberculosis risk assessment, in the record for Resident #10, was dated 5/16/18. The risk assessment was more than a year old, at the time of the inspection.
Plan of Correction:	Resident #10 annual tuberculosis assessment was conducted at physician?s office September 10, 2019. Community obtained copy via fax on 9/24/2019 and placed in medical record. Assessment indicated resident was free from tuberculosis. Resident Care Director or designee will complete an audit of current residents to confirm annual TB assessments. Issues identified will be addressed and resolved. The RCD will audit resident records monthly via the electronic medical record system for 3 months to confirm annual TB assessments and present the results to the QAPI committee. Issue identified will be addressed and resolved. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the audits of resident annual risk assessments for tuberculosis and determine if additional focus or action is warranted. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the audits of resident annual risk assessments for tuberculosis and determine if additional focus or action is warranted.
Standard #:	22VAC40-73-450-C
Description:	Based on record review, the facility failed to ensure that the comprehensive individualized service plan (ISP), is based upon the uniform assessment instrument (UAI). Evidence: The UAI for Resident #4, dated 9/5/19, states that the resident needs only physical assistance for bathing and transferring. The ISP for Resident #4, dated 9/15/19, states that the resident needs mechanical and physical assistance for bathing and transferring. The UAI for Resident #5, dated 6/17/19, states that the resident needs only physical assistance for bathing. The ISP for Resident #5, dated 6/23/19, states that the resident needs needs mechanical and physical assistance for bathing. The UAI for Resident #6, dated 8/15/19, states that the resident needs only supervision for bathing and only mechanical assistance for walking. The ISP for Resident #6, dated 8/18/19, states that the resident needs both mechanical assistance and supervision for bathing and walking.
Plan of Correction:	Residents 4, 5 and 6: their ISPs and UAIs were updated by the ALC and RC to reflect the required mechanical assistance and supervision for bathing and walking. The Assisted Living Coordinator and Reminiscence Coordinator conducted an audit of UAIs and ISPs for current residents to confirm that the documentation regarding mechanical assistance and supervision for bathing and walking is reflected. Issues identified were addressed and resolved. Resident Care Director will conduct a refresher training course with the Assisted Living Coordinator and Reminiscence Coordinator regarding the process for updating the ISPs and UAIs with a focus on confirming that mechanical assistance and supervision for bathing and walking is reflected. Assisted Living Coordinator and Reminiscence Coordinator will audit UAIs and ISPs for current residents to confirm that the documentation regarding mechanical assistance and supervision for bathing and walking is reflected - monthly for 3 months. Issues identified will be addressed and resolved. The audit results will be presented at QAPI meetings. During and at the end of the 3 months, the QAPI Committee will evaluate the results of the UAI/ISP audits and determine if additional focus or action is warranted. 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.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation and record review, the facility failed to ensure that medication is kept in the locked medication storage area. Evidence: Cortizone 10 and Clotrimazole-Betamethasone creams were observed to be unlocked and unattended in the bathroom of Resident #8, of the special care unit. The uniform assessment instrument (UAI) for Resident #8, dated 5/19/19, states that the resident needs staff assistance for medication administration.
Plan of Correction:	Resident #8 Cortizone10 and Clotrimazole Beamethasone creams that were brought in by family were removed from suite. Family of Resident #8 was called by the RC and reminded of medication requirements. Reminiscence Coordinator conducted and inspection of the resident suites to confirm compliance with medication storage standards. No other issues were identified. Assisted Living Coordinator and Reminiscence Coordinator will provide communication to Families/Responsible Parties of medication storage requirements via email/letter. The Assisted Living Coordinator, Reminiscence Coordinator and/or designee will complete room observations weekly for 3 months to confirm medication storage requirements and present the results to the QAPI committee. Issues identified will be addressed and resolved. During and at the end of the 3 months, the QAPI Committee will evaluate the results of suite observations and determine if additional focus or action is warranted. 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.