VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Hills Mt. Vernon
3709 Shannons Green Way
Alexandria, VA 22309
(703) 780-7100

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Feb. 13, 2020 , Feb. 14, 2020 , Feb. 24, 2020 and March 2, 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.

Technical Assistance:

Please provide a copy of the facility's current, passed, full-system fire inspection report to your inspector as required prior to the issuance of a renewal of the facility's ALF license. Discussed with Administrator and Director of Nursing the elimination of the inconsistent use of stickers (bedtime, a.m, p.m.) added to the pharmacy labels on blister packets of medications that are not consistent with the facility Medication Management Plan and provider orders; Although observed stickers did not result in an observation of a medication error during the study, this practice may result in confusion and a potential medication error at a future date. Discussed nonambulatory and ambulatory status of residents, particularly in safe, secure area. Discussed that all First Aid and CPR certifications shall be provided by an approved organization per standard 260. Discussed that incident reports to the Department of Social Services (DSS) are required for all wounds greater than Stage 1 and for all wounds that are not staged and require treatment. Discussed that all DSS model forms if used by the facility shall be the most recent forms (www.dss.virginia.gov). Discussed all timeline requirements for tuberculosis screenings required by DSS and must be on or consistent with the Virginia Department of Health form indicating free of communicable disease.

Comments:

An unannounced renewal study was conducted from 9:00 a.m. - 6:30 p.m. on 02/13/2020 and 9:00 a.m. - 5:30 pm. on 2/14/2020. At the time of entrance 77 residents were in care. The sample size consisted of ten resident records and five staff records. Five residents, one family member and staff were interviewed. Resident, staff, volunteer and pet records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection conducted on 12/05/2018 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including Valentine Fun Facts, Ice Cream Social, SingFit Music Therapy in assisted living and Daily Chronicles, Children Recital and Bible music sing-a-long, and SingFit Music Therapy in the safe, secure area. Medication administration was observed with two staff. Medication carts observed for PRN medications. Building and Grounds observed. Licensing Inspector (LI) returned on 2/24/2020 to review documentation that was not available during the study and documentation sent to LI via email on 2/28/2020 was reviewed by LI on 3/2/2020. Violation notice issued, risk ratings reviewed and exit interview held on 2/14/2020 with Administrator and Director of Nursing. 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) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

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 clinical psychologist licensed to practice in the Commonwealth 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 #6 was admitted on 1/28/2020 with an Assessment of Serious Cognitive Impairment signed by a physician on 1/20/2020 who answered no to the question that asked if the individual named has as a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his/her own safety and welfare.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review, facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate and the determination and justification for the decision shall be in writing and shall be retained in the resident's file. Evidence: 4/6 records reviewed of residents residing in the safe, secure area did not include documentation signed by the administrator or designee to determine whether placement in the special care unit is appropriate. Resident #4 was admitted on 1/24/2020, Resident #5 was admitted on 3/31/2018, Resident #6 was admitted on 1/28/2020 and Resident #8 was admitted on 10/25/2018 and a written justification prior to admission signed by the administrator or designee was not in record for Residents #4, #5, #6 and #8.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on record review, facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination and shall contain the results of a risk assessment documenting the absence of tuberculosis and shall contain any known allergies and description of the person's reactions. Evidence: Resident #5 was admitted on 3/31/2018 with an admission progress note in record on 4/6/2018 and the only physical examination report and tuberculosis screening observed in record were dated 4/1/2019 with a documented allergy to peanuts and a reaction to the allergy was not documented. Resident #4 was admitted on 1/24/2020 with a physical examination on 1/15/2020 that documented an allergy to penicillin and did not document the reaction to the allergy. Resident #6 was admitted on 1/28/2020 with a physical examination on 1/21/2020 that documented an allergy to codeine, doxycycline, erythromycin, Iodine, levaquin and Linocin and the reactions to the allergies were not documented.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-660-B
Description:	Based on observation and record review, facility failed to ensure that a resident may be permitted to keep his own medication in an out-of-sight place in his room if the UAI has indicated that the resident is capable of self-administering medication and the medication shall be stored so that they are not accessible to other residents. Evidence: Resident #8 resides in a safe, secure area and a bottle of Tums was observed on a bedside table in the unlocked resident's room and most recent UAI dated 12/2/2019 documents that medication administration shall be administered/monitored by professional nursing staff.
Plan of Correction:	Not available online. Contact Inspector for more information.