VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Sylvestery
1728 Kirby Road
Mc lean, VA 22101
(703) 970-2700

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: June 11, 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.

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 6/11/2020 and concluded on 6/19/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 32. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records and 3 staff records. Criminal record checks and sworn statements of all staff hired since last inspection and other documentation submitted by the facility was reviewed to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review, facility failed to ensure that prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent psychologist or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: Resident #1 was admitted on 5/30/2019 with an Assessment signed and dated on 5/29/2019 that documented an answer "no" to the question "is the individual named above unable to recognize danger or protect his/her own safety and welfare?"
Plan of Correction:	The Clinical Manager and/or designee are auditing all resident records to ensure that all residents residing in a secure environment have the appropriate diagnosis and form, evidencing assessment by an independent healthcare professional. Resident #1 as cited has ?no? checked to the question, ?is the individual named above unable to recognize danger or protect his/her own safety and welfare?? Prior to placement in a safe, secure environment, the Clinical Manager will ensure the Virginia form for Assessment of Serious Cognitive Impairment is completed, check for accuracy and signed by the resident's physician or clinical psychologist, noting the appropriate diagnosis and need for a safe, secured environment. The signed form is kept in the resident's wellness file. The Administrator or designee is responsible for ensuring implementation and ongoing compliance with all components of this Plan of Correction and addressing and resolving any variance that may occur.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment. Evidence: 1/5 staff records reviewed did not document a sworn statement (SS) completed as applicant. Staff #5 was hired on 5/9/2020 with a SS in record that is not signed and is dated 6/5/2020 after hired date, not an applicant.
Plan of Correction:	With respect to the specific employee/situation cited: based on record review, facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment. The HR Generalist, or designee, will review current employee records and verify the sworn statement is signed and dated and is in the record. The HR generalist or designate will perform audits of sworn statements monthly for three months, which will be presented at the QAPI Meeting for 3 months. During and at the conclusion of each month, the QAPI committee will re-evaluate and initiate necessary action, or extend the review period. The Administrator and/or designee is responsible for confirming implementation and ongoing compliance with the components of this plan of correction and addressing and resolving variances that may occur.