VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Jefferson
900 North Taylor Street
Arlington, VA 22203
(703) 516-9455

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: Nov. 13, 2019 and Nov. 14, 2019

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:

An unannounced renewal inspection was conducted on 11/13/19 (8:15 AM - 6:45 PM) and 11/14/19 (8:00 AM - 12:15 PM). At the time of entrance, 56 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected and records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and an exit meeting was held. 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on record review and interview, the facility failed to ensure that the required written approval is obtained, prior to placing a resident in the in the safe, secure environment. Evidence: The resident record indicated that Resident #1 was placed in the safe, secure environment on 7/13/19. No written approval, from Resident #1 or his legal representative, was contained in the resident record. Facility staff confirmed that the approval was not present in the record.
Plan of Correction:	The written approval for placement in a safe, secure environment was sent to the legal representative for Resident #1 on 12/2/19 for signature. An audit of admission files for residents admitted to the safe, secure environment within the last six months and still residing in the facility was conducted by the Administrator to verify that written approval for placement in a safe, secure environment from the resident?s legal representative was present. One additional file was found to be missing the written approval for placement in a safe, secure environment from the resident?s legal representative. The signed acknowledgement of resident orientation was obtained by the Reminiscence Coordinator on 11/27/19. Refresher training will be conducted by the Director of Sales for the Assisted Living Facility leadership team regarding the requirement to obtain written approval for placement in a safe, secure environment from the resident?s legal representative, and using the administrative file checklist. New admission records for residents admitted to the safe, secure environment will be audited monthly for the next three months by the Director of Sales or his designee to verify that the written approval for placement in a safe, secure environment was obtained from the resident?s legal representative. Over the next three months, the results of these admission record audits will be reviewed at Quality Assurance / Performance Improvement Meetings. During and at the conclusion of three months, the QAPI committee will reevaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review and interview, the facility failed to ensure that, prior to admitting a resident with serious cognitive impairment; the licensee, administrator, or designee determines whether placement in the special care unit is appropriate. The determination and justification for the decision shall be retained in the resident's file. Evidence: The resident record indicated that Resident #1 was placed in the safe, secure environment on 7/13/19. No admission approval document was included in the record for Resident #1. Facility staff confirmed that the admission approval document was not present in Resident #1's record.
Plan of Correction:	The written approval for placement in a safe, secure environment for Resident #1 was signed by the administrator at the time of the survey. An audit of admission files for residents admitted to the safe, secure environment within the last six months and still residing in the facility was conducted by the Administrator to verify that written approval from the licensee, administrator or designee for placement in a safe, secure environment was present. One additional file was found to be missing the written approval from the licensee, administrator or designee for placement in a safe, secure environment. The written approval was signed by the Administrator and placed in the resident?s file at the time of the audit. Refresher training will be conducted by the Director of Sales for the Assisted Living Facility leadership team regarding the requirement to obtain written approval for placement in a safe, secure environment from the licensee, administrator or designee, and using the administrative file checklist. New admission records for residents admitted to the safe, secure environment will be audited monthly for the next three months by the Director of Sales or his designee to verify that the written approval for placement in a safe, secure environment was obtained from the licensee, administrator or designee. Over the next three months, the results of these admission record audits will be reviewed at Quality Assurance / Performance Improvement Meetings. During and at the conclusion of three months, the QAPI committee will reevaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-260-A
Description:	Based on record review, the facility failed to ensure that each direct care staff member maintains certification in first aid. Each direct care staff member who does not have current certification in first aid shall receive certification in first aid within 60 days of employment. Evidence: Current first aid certification was not contained in the records of Staff #2 (hired 6/3/19) and Staff #3 (hired 12/8/08). The records contained documentation of CPR certification, but not first aid.
Plan of Correction:	Staff member #2 and #3 are scheduled for First Aid certification class on 12/12/19 and12/14/19. The HR Assistant completed a review of employee files to verify that First Aid certifications are current. One other staff member was identified with an expired First Aid certification. This staff member was also scheduled for First Aid certification class on 12/14/19. First Aid certification expiration dates will be tracked on the HR tickler sent to managers monthly. If a staff member does not have a current First Aid certification on file, they will be scheduled for the next available class. If they fail to complete the next scheduled class, they will be removed from the schedule until a current First Aid certification is obtained. The HR Assistant or her designee will audit five randomly selected staff files for the next three months to verify that they have current First Aid certifications. Over the next three months, the results of these audits will be reviewed at Quality Assurance / Performance Improvement meetings. During and at the conclusion of three months, the QAPI committee will reevaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-410-A
Description:	Based on record review, the facility failed to ensure that orientation is provided for new residents and their legal representatives. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident's record. Evidence: Resident #1's record was reviewed during the inspection. The record indicated that Resident #1 was admitted on 7/13/19. The orientation acknowledgment, included in Resident #1's record, was not signed by the resident or his legal representative.
Plan of Correction:	The orientation acknowledgement was sent to the legal representative for Resident #1 on 12/2/19 for signature. An audit of admission files for residents admitted within the last six months and still residing in the facility was conducted by the Administrator to verify that the orientation acknowledgement was signed by the resident?s legal representative. No discrepancies were found during the audit. Refresher training will be conducted by the Director of Sales for the Assisted Living Facility leadership team regarding the requirement to provide an orientation for new residents and their legal representatives, and using the administrative file checklist. New admission records will be audited monthly for the next three months by the Director of Sales or his designee to verify that the orientation acknowledgement is signed. Over the next three months, the results of these admission record audits will be reviewed at Quality Assurance / Performance Improvement Meetings. During and at the conclusion of three months, the QAPI committee will reevaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-660-A-1
Description:	Based on observation, the facility failed to ensure that the medication storage area remains locked. Evidence: During the inspection, a fourth floor medication cart was observed to be unlocked and unattended.
Plan of Correction:	Upon identification, the fourth floor medication cart was locked at the time of the survey. Staff member #1 who left the medication cart unlocked and unattended was given refresher training by the Assisted Living Coordinator regarding proper storage of medications. Other medication carts were checked at the time of the survey by the Healthcare Operations Manager and found to be locked when unattended. Refresher training will be conducted by the Reminiscence Coordinator (LPN) for nurses and medication aides regarding proper storage of medications and locking the cart when unattended. Over the next three months, the Assisted Living and Reminiscence Coordinators or their designees will conduct random observations of medication carts at least three times a week to verify that carts are locked when unattended. The results of these weekly medication cart observations will be reviewed at Quality Assurance / Performance Improvement meetings. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-680-D
Description:	Based on observation and documentation, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: The morning medication administration, for Resident #2, was observed during the inspection. Four pills were placed in the resident's pill cup and the resident's medications were returned to the cart. Resident #2's medication administration record (MAR), indicated that the resident was scheduled to receive six pills, during the medication administration. Mybetriq and Vitamin D, were not placed in Resident #2's pill cup. The morning medication administration, for Resident #8, was observed during the inspection. Facility staff organized Resident #8's medications for administration and placed her pills in a pill cup. Nasal spray was removed from the package and was going to be administered to Resident #8. Before the medication was administered, the licensing inspector asked about the nasal spray. The nasal spray, that had been removed from the cart for administration, was Resident #5's Mometasone. Resident #8's MAR indicated that she was scheduled to receive Flonase, during the medication administration.
Plan of Correction:	Upon identification, Resident #2 and Resident #8 received their medications in accordance with the physician?s instructions at the time of the survey. Staff member #1 who administered the morning medications for Resident #2 and Resident #8 was given refresher training by the Assisted Living Coordinator regarding administering medications in accordance with physician orders. Medication pass observations will be conducted with RMAs and LPNs responsible for medication administration by the Wellness Nurse or designee over the next 2 weeks to validate that they are administering medications in accordance with physician orders. If incorrect practice is observed, on-the-spot training will be provided and additional observations will be conducted to validate correct practice. Refresher training will be conducted by the Reminiscence Coordinator (LPN) for nurses and medication aides regarding administering medications in accordance with physician orders. Medication pass observations will be conducted with RMAs and LPNs responsible for medication administration by the Wellness Nurse or designee monthly for the next three months to validate that they are administering medications in accordance with physician orders. If continued incorrect practice is observed, the staff member will removed from the assignment and placed back on orientation until consistent correct practice can be confirmed. The results of these monthly med pass observations will be reviewed at Quality Assurance / Performance Improvement meetings. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-680-M
Description:	Based on observation and interview, the facility failed to ensure that medications ordered for PRN administration are available and properly stored at the facility. Evidence: Resident #8's PRN Tylenol 500mg, Miralax, and Enema were not available for administration, at the time of the medication cart inspection. Facility staff confirmed that the medications were not present, at the time of the medication cart inspection.
Plan of Correction:	The PRN Tylenol 500mg, Mirilax and Enema for resident #8 were obtained at the time of survey and are currently available on the medication cart. An audit of current PRN medication orders was conducted by the Administrator and her designees to verify that medications are available at the facility. Medications that were not available on the cart were re-ordered at the time of the audit. Refresher training will be conducted by the Reminiscence Coordinator (LPN) for nurses and medication aides regarding the need for ordered medications to be available in the facility. The night nurse will audit medication carts against active PRN orders weekly, reconcile missing PRN medications with pharmacy deliveries, and re-order any missing medications. The Wellness Nurse or designee will verify availability of re-ordered medications on the medication cart on a weekly basis for 3 months. In addition to the weekly medication cart audits, the Administrator or her designee will randomly audit five PRN medication orders monthly for the next three months to verify that the medications are available in the facility. Over the next three months, the results of these audits will be reviewed at Quality Assurance / Performance Improvement Meetings. During and at the conclusion of three months, the QAPI committee will reevaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.