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: April 2, 2021 and April 6, 2021

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 monitoring inspection was initiated on 4/02/2021 and concluded on 4/06/2021. The administrator was contacted by telephone for an entrance interview to initiate the inspection. The administrator reported that the current census was 62. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records and four 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. Exit interview conducted with administrator and management team on 4/14/2021. 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. 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; 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s); and 4) date that that plan of correction will be completed. 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 #1 was admitted to a safe, secure environment on 9/03/2020 with an assessment of serious cognitive impairment dated 9/07/2020, not prior to admission.
Plan of Correction:	The Director of Resident Care services (DRC) to conduct a 100% audit of all residents with primary diagnosis of serious cognitive impairment to ensure they were assessed prior to admission. The Director of Residential Care (DRC) will review documentation prior to move in using the ?new admission checklist? to verify that required documentation is present prior to admission. The Executive Director will perform an audit on 25% of new move in files quarterly to verify compliance using the community quality assurance tool.
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. Evidence: Resident #2 was admitted to a safe, secure environment on 1/06/2020 with an appropriateness documented on 2/25/2020, not prior to admission.
Plan of Correction:	The Director of Resident Care services (DRC) to conduct a 100% audit of all residents with primary diagnosis of serious cognitive impairment to ensure they were assessed prior to admission to determine placement. The Director of Residential Care (DRC) will review documentation prior to move in using the ?new admission checklist? to verify that required documentation is present prior to admission. The Executive Director will perform an audit on 10% of new move in files quarterly to verify compliance using the community quality assurance tool.
Standard #:	22VAC40-73-250-A
Description:	Based on record review, facility failed to ensure that a record shall be established for each staff person and it shall not be destroyed until at least two years after employment is terminated. Evidence: Staff #4 was listed as a wellness nurse on staff roster provided by facility on 3/31/2021 with a date of hire on 6/04/2020 and Staff #4's termination date was on 4/02/2021 and a staff record of the verification of current professional license and tuberculosis report was not maintained for at least two years after employment is terminated.
Plan of Correction:	The Executive Director will in-service all managers on company?s policy and regulation pertaining to preserving and destruction of staff records.
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: 1/16 records reviewed did not document a Sworn Statement (SS) completed as an applicant; Staff #2 was hired on 2/19/2021 with a SS signed as an employee on 2/23/2021.
Plan of Correction:	The Business Office Manager (BOM) to conduct a 100% audit on all current staff records to ensure a sworn statement or affirmation was obtained and filed. The Business Office Manager (BOM) will review documentation prior to employment by utilizing Excelforce credentialing process according to company policy to ensure that all associate credentials are completed in accordance to DSS and company standards. The Executive Director will perform an audit on 25% of new employee files quarterly to verify compliance using the community credentialing tool.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. Evidence: 2/16 staff records did not document a Criminal History Record (CHR) prior to the 30th day of employment; Staff #14 was hired in dining on 8/05/2020 with a CHR dated 4/01/2021 and Staff #15 was hired in housekeeping on 4/19/2020 with a CHR dated 11/30/2020.
Plan of Correction:	The Business Office Manager (BOM) to conduct a 100% audit on all current staff records to ensure a criminal history record was obtained and filed prior to 30 days of employment. The Business Office Manager (BOM) will review documentation prior to employment by utilizing Excelforce credentialing process according to company policy to ensure that all associate credentials are completed in accordance with DSS and company standards. The Executive Director will perform an audit on 25% of new employee files quarterly to verify compliance using the community credentialing tool.