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: March 13, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 63.2 PROTECTION OF ADULTS AND REPORTING

Comments:

A complaint was received by VDSS Division of Licensing on 1/10/2023 regarding allegations in the areas of documentation and service plan delivery. Licensing Inspector (LI) conducted unannounced complaint investigation on 3/13/2023. LI reviewed resident records and conducted staff interviews. The evidence gathered during the investigation did not support the allegation of non-compliance with standard(s) or law. The inspection summary will be posted to the VDSS website within 5 business days of your receipt of the inspection summary. 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. The department's inspection findings are subject to public disclosure. 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 #:	22VAC40-73-310-H
Complaint related:	No
Description:	Based on documentation facility failed to ensure that in accordance with ? 63.2-1805 D of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs: individuals requiring continuous licensed nursing care. Evidence: Resident #1?s admission health and physical dated 9/30/2022 indicates that the resident requires continuous licensed nursing care.
Plan of Correction:	The community has twenty four hour LPN oversight. In the absence of an Executive Director and Director of Resident Care- the H&P was not revised by the physician to not reflect 24 hour care. The resident physician will be contacted for revision to accurately reflect ALF services per standards. The newly pointed Director of Resident Care will audit resident admission files in order to identify any discrepancies on admission paperwork
Standard #:	22VAC40-73-325-C
Complaint related:	Yes
Description:	Based on documentation and interview facility failed to ensure that the facility must document an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. Evidence: The current facility fall risk rating does not include documentation of interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of Correction:	The community will ensure the fall risk rating is accurately updated for the identified resident. Despite documentation failure- several in person care coordination meetings were held with hospice provider and resident Power of Attorney to discuss resident?s risk of falls. The newly appointed Director of Resident Care will audit fall risk plans for appropriate residents
Standard #:	22VAC40-73-450-C
Complaint related:	No
Description:	Based on documentation and interview facility failed to ensure that the comprehensive Individualized Service Plan (ISP) shall be completed within 30 days after admission. Evidence: Resident #1 admitted 9/30/2022 did not have documentation that a comprehensive ISP was completed within 30 days.
Plan of Correction:	The community had a lapse in Director of Resident Care at the time of admission. A service plan was completed and coordinated with hospice and Power of Attorney. The care plan will be updated immediately to reflect comprehensive care. The newly appointed Director of Resident Care will audit service plans on or before 4/13/23 to identify any discrepancies in comprehensive ISP documentation.
Standard #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on documentation and interview facility failed to ensure that when hospice care is provided to a resident, the services provided by each shall be included on the individualized service plan. Evidence: Resident #1 receives hospice services. These services are not documented on the resident?s most recent ISP.
Plan of Correction:	Coordination of care did occur with the resident?s hospice provider. In the absence of a Director of Resident Care there was a lapse of documentation on the resident ISP. The newly appointed Director of Resident Care will audit ISP?s with outside services to ensure coordination of care is accurately reflected on the ISP
Standard #:	22VAC40-73-460-D
Complaint related:	Yes
Description:	Based on documentation and interview facility failed to ensure that it shall provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as prevention of falls and wandering from the premises. Evidence: Resident #1?s incident notes indicate that the resident experienced unwitnessed falls on 10/5/2022, 10/27/2022, 12/24/2022,1/11/2023,1/15/2023. 1/26/2023,2/9/2023 and 2/15/2023. Staff did not attend to the resident?s specialized needs.
Plan of Correction:	Documentation of appropriate interventions will occur to ensure resident?s needs are appropriately met. Hospice was notified and care coordination meetings occurred in response to the resident?s risk of falls. The newly appointed Director of Resident Care will educate wellness nurses to ensure care coordination is appropriately documented
Standard #:	22VAC40-73-470-F
Complaint related:	Yes
Description:	Based on documentation and interview facility failed to ensure that when the resident suffers serious accident, injury, illness, or medical condition, or there is reason to suspect that such has occurred, medical attention from a licensed health care professional shall be secured immediately. Evidence: As documented in the Resident #1?s incident notes, on 1/26/2023 the resident experienced a fall that resulted in a laceration, bruising and swelling around the resident?s eye and face. Medical attention was not sought out until 1/31/2023.
Plan of Correction:	The resident is on hospice services. Both the medical POA and hospice were notified of all incidents that occurred and appropriate treatment at the time of the incidents was agreed upon and discussed. The newly appointed DRC will conduct education to ensure that appropriate documentation occurs in the resident?s record to ensure the appropriate treatment plan that was agreed to
Standard #:	22VAC40-73-480-E
Complaint related:	No
Description:	Based on documentation and interview the facility failed to ensure that the physician's or other prescriber's orders, services provided, evaluations of progress, and other pertinent information regarding the rehabilitative services shall be recorded in the resident's record. Evidence: Resident #1 receives hospice services. There is no documentation in the resident record to indicate that hospice visits have been conducted.
Plan of Correction:	The resident is on hospice services. Both the medical POA and hospice were notified of all incidents that occurred and appropriate treatment at the time of the incidents was agreed upon and discussed. The newly appointed DRC will conduct education to ensure that appropriate documentation occurs in the resident?s record to ensure the appropriate treatment plan that was agreed to