VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Waltonwood Ashburn
44145 Russell Branch Parkway
Ashburn, VA 20147
(571) 918-4854

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Jan. 6, 2022 and Feb. 4, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Licensing Inspector (LI) conducted unannounced complaint investigation on 1/06/2022 regarding the administration of medications by unlicensed or unqualified staff. LI reviewed staff work schedules, staff qualifications, medication administration records, and interviewed administrative staff. Complaint regarding Standards 670-1 and 680-A is deemed valid as a preponderance of evidence gathered during the investigation supported the allegations of non-compliance. Exit interview conducted on 2/04/2022 and the violation notice regarding the standards deemed valid was emailed to the administrator. 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 703-479-5247 or contact me via email at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-670-1
Complaint related:	No
Description:	Based upon a review of staff work schedules and staff records, the facility failed to ensure that each staff person who administers medication shall be authorized by ? 54.1-3408 of the Virginia Drug Control Act, and all staff responsible for medication administration shall either be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. Evidence: 1. According to the staff records, the following individuals working for Holding Hands Home Care and assigned to work at Waltonwood Ashburn to administer medications did not have the required qualifications to administer medications: A. Staff #1?s medication technician license from the State of Maryland expired on 4/28/2021. B. Staff #2?s certification is for Personal Care Aide and was obtained on 2/3/2019. C. Staff #3 has a current medication technician license from the State of Maryland. Staff #3 according to an interview with Resident Care Manager on 1/27/2022, has neither applied to take nor has taken the Virginia State medication aide examination. According to the Virginia Board of Nursing: 18VAC90-60-92. Requirements for registration by endorsement: an applicant applying for registration by endorsement who has met the requirements for registration or certification as a medication aide in another state or the District of Columbia may be deemed eligible to sit for the state examination if there are no grounds for denial of registration as specified in ? 54.1-3007 of the Code of Virginia and upon submission of: 1. A completed application and fee; and 2. Verification of registration or certification as a medication aide in another state or the District of Columbia, which is current or eligible for reinstatement. D. Staff #4 has certification as a certified nurses? assistant. 2. Work schedules document that individuals working for Holding Hands Home Care were assigned to administer medications at Waltonwood Ashburn during the following shifts without having the required qualifications to administer medications: A. Staff#1: 1. 11/21/2021--7am to 3:30pm and 3:00pm to 11:30pm 2. 11/26/2021?3:00pm to 11:30pm 3. 11/29/2021?7am to 3:30pm and 3:00pm to 11:30pm 4. 11/30/2021?3pm to 11:30pm 5. 12/3/2021?7am to 3:30pm 6. 12/5/2021?7am to 3:30pm B. Staff #2: 1. 11/25/2021?3pm to 11:30pm 2. 12/7/2021?3pm to 11:30pm 3. 12/9/2021?11pm to 7:30am 4. 12/11/2021?11pm to 7:30am C. Staff#3: 1. 11/28/2021?11pm to 7:30am 2. 12/7/2021?11pm to 7:30am 3. 12/8/2021?11pm to 7:30am D. Staff #4: 1. 12/13/2021?7am to 3:30pm
Plan of Correction:	List of outside agency staff scheduled to work at Waltonwood will be reviewed by Resident Care Manager or Scheduler prior to their arrival at the building to ensure that licenses and credentials are in the binder. Resident Care Manager or Scheduler will monitor the licenses and certifications for expiration dates on a monthly basis to ensure compliance with the regulations for the State of Virginia.
Standard #:	22VAC40-73-680-A
Complaint related:	No
Description:	Based upon a review of staff work schedule, medication administration records, and interviews with administrative staff, the facility failed to ensure that staff who are licensed, registered, or acting as medication aides on a provisional basis as specified in 22VAC40-73-670 shall administer drugs to those residents who are dependent on medication administration as documented on the UAI. Evidence: 1. Interview with Resident Care Manager (RCM) on 1/6/2022 and with the Executive Director (ED) on 1/6/2022, the facility used outside agencies to help with staffing shortages including in the position of medication technicians. The RCM reported during the interview that some of the staff used in positions of medication technicians did not have the required certification to administer medications and those individuals did administer medications to residents. 2. Work schedules and medication administration records document that individuals working for Holding Hands Home Care and assigned to work at Waltonwood Ashburn administered medications without required qualifications on the following shifts: A. Staff#1: 1. 11/21/2021--7am to 3:30pm and 3:00pm to 11:30pm 2. 11/26/2021?3:00pm to 11:30pm 3. 11/29/2021?7am to 3:30pm and 3:00pm to 11:30pm 4. 11/30/2021?3pm to 11:30pm 5. 12/3/2021?7am to 3:30pm 6. 12/5/2021?7am to 3:30pm E. Staff #2: 1. 11/25/2021?3pm to 11:30pm 2. 12/7/2021?3pm to 11:30pm 3. 12/9/2021?11pm to 7:30am 4. 12/11/2021?11pm to 7:30am F. Staff#3: 1 .11/28/2021?11pm to 7:30am 2. 12/7/2021?11pm to 7:30am 3. 12/8/2021?11pm to 7:30am G. Staff #4: 1. 12/13/2021?7am to 3:30pm
Plan of Correction:	Outside agencies have been notified and asked to provide credentials, licenses, and certifications for all agency staff sent to fill shifts. Credentials for LPNs, Med Techs, CNAs, and PCAs are being placed in a binder located within the Resident Care Manager's office. The binder has been sectioned by LPN, Med Tech, PCA, and CNA. Expiration dates are being highlighted for easy reference. Information within the binder will be reviewed monthly.