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: Dec. 9, 2020

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. 22VAC40-80 THE LICENSING PROCESS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 12/9/20 and completed on 12/18/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the census was 71. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. 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 #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member annually submits the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The record for Staff #3, hired 1/5/18, was reviewed during the inspection. The record contained a tuberculosis symptom screening form, dated 1/23/20, that was completed by Staff #3. The screening form did not document that Staff #3 was free of tuberculosis in a communicable form and the screening form was not consistent with a screening form published by the Virginia Department of Health.
Plan of Correction:	Team member #3 completed a TB risk assessment on 12/10/2020. Reviewed and signed by Nurse Practitioner verifying TM was negative for signs and symptoms of TB. The assessment was added to Team Member #3's record. The Business Office Coordinator (BOC) and ED will conduct an audit of team member files to confirm TB assessment requirements. BOC and ED will conduct monthly audits of newly hired team members TB records and annual TB assessments for 3 months. The Business Office Coordinator (BOC) and Executive Director (ED) will utilize software tracking system to manage TM annual requirement compliance. Business Office Coordinator (BOC) will provide ED monthly report for additional verification of compliance. Additionally, BOC contacted contracted Employee Health Provider and shared TM screening requirements to further manage compliance with further TB screening. Regional Human Resource Representatives will provide additional oversight to support compliance. Each month, for 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the Team Record audits specific to TB Screening 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 #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: The November medication administration record (MAR) for Resident #2 was reviewed during the inspection. The MAR stated that Resident #2 did not receive his Lidoderm patch on 11/2/20. The MAR stated that the patch was "pending delivery." The November MAR for Resident #4 was reviewed during the inspection. The MAR stated that Resident #4 did not receive her Coreg on 11/30/20 (8 AM administration). The MAR stated that the Coreg was "pending delivery."
Plan of Correction:	Resident #2 Lidoderm Patch was received from the pharmacy on November 2, 2020 and administered on 11/3/2020 as ordered by physician and confirmed by the Resident Care director (RCD). Resident #2 demonstrated no known negative outcomes. Resident #4 Coreg was received from the pharmacy on November 30, 2020 and was administered upon arrival that evening to Resident #4. Resident #4 demonstrated no negative outcomes from delayed administration. Resident Care Director (RCD) performed an audit of the medication administration records and medication carts as it relates to medication pending delivery; No issues were identified. Resident Care Director (RCD) has conducted refresher training with the Medication Managers on the process for following up with the pharmacy, the physician, proper documentation and measures to prevent unavailable medications. Resident Care Director (RCD) will discuss this process at the monthly Medication Managers meetings over the next 3 months. The Medication Managers (MCM) and Wellness Nurses were re-educated by the RCD regarding the process to follow when a medication is pending delivery. Resident Care Director (RCD), or designee will conduct weekly audits for 2 weeks, monthly audits for 2 months to confirm medications are available per physician's orders on the medication cart. Issues that may be identified will be addressed and resolved. A refresher training initiated as needed. During and at the end of the 3 months, the Quality Assurance and Performance Improvement (QAPI) committee will evaluate the results of the medication administration audits specific to medication pending delivery 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.