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: Jan. 5, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 63.2 Protection of adults and reporting.

Technical Assistance:

Please note: The facility will review their policy regarding secondary notifications when the primary notification cannot be made. Also, it should be indicated in the resident record when multiple notifications have been requested for a resident. Please ensure that internal facility investigatory notes and reports are complete and kept on file. Discussed upcoming renewal inspection. Please ensure that a renewal application is submitted prior to the current license expiring.

Comments:

A complaint was received by VDSS Division of Licensing on 12/16/2022 regarding allegations in the areas of notifications, documentation and resident injury. Licensing Inspector (LI) conducted unannounced complaint investigation on 1/5/2023. LI reviewed resident records and conducted staff interviews. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violation not related to the complaint but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violations will be addressed in order to return the facility to compliance and maintain future compliance with applicable standards or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Lynette Storr, Licensing Inspector at (703) 479-4708 or by email at lynette.storr@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on interview and documentation review the facility failed to ensure that a report was made to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: On 11/20/2022 Resident #1 was observed by direct care staff as having discoloration on the upper left eye and a bruise on the roof of his nose. The origin of this injury is unknown. This incident was not reported to the regional licensing office.
Plan of Correction:	All incidents will be reported to the regional licensing office as required. Education will be provided on Incident Reporting and Mandated Reporting requirements on 1/10/23. Training will occur bi-annually and on an ongoing basis.
Standard #:	22VAC40-73-130-A
Complaint related:	Yes
Description:	Based on interview and documentation the facility failed to ensure that all staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia shall report suspected abuse, neglect, or exploitation of residents in accordance with that section. Evidence: On 11/20/2022 Resident #1 was observed by direct care staff as having discoloration on the upper left eye and a bruise on the roof of his nose. The origin of this injury is unknown. This incident was not reported to Adult Protective Services
Plan of Correction:	All applicable incidents will be reported to APS as required. Education will be provided on Incident and Mandated Reporting Requirements on 1/10/23. Training will occur bi-annually and on an ongoing basis.
Standard #:	22VAC40-73-560-E
Complaint related:	No
Description:	Based on documentation and interview the facility failed to ensure that all resident records shall be kept current. Evidence: On 11/20/2022 Resident #1 was observed by direct care staff as having discoloration on the upper left eye and a bruise on the roof of his nose. The origin of this injury is unknown. This incident was not recorded in the resident until 11/22/2022. The progress note did not indicate the care giver that reported the injury.
Plan of Correction:	All documentation will occur timely and accurately in the resident record. Progress notes will be reviewed to ensure documentation is completed and up to date. Education will be provided on documentation and incident reporting requirements on 1/10/23. Training will occur bi-annually and on an ongoing basis.