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: Feb. 9, 2022

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. 22VAC40-80 THE LICENSING PROCESS.

Comments:

An unannounced renewal inspection was conducted on 2/9/22. At the time of entrance, 53 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 #:	22VAC40-73-250-D
Description:	Based on record review, the facility failed to ensure that each staff member annually submits the results of a tuberculosis risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. Evidence: The record for Staff #1 was reviewed during the inspection. Staff #1's file included a tuberculosis risk assessment form, dated 12/20/21. The risk assessment form did not include information about the conclusion of screening/testing. The record for Staff #3 was reviewed during the inspection. Staff #3's file included a tuberculosis risk assessment form, dated 5/6/21. The risk assessment form did not include information about the conclusion of the screening/testing. Staff #3's record contained the results of a chest X-ray as well, but it was not completed within the past year.
Plan of Correction:	The tuberculosis risk assessments for Staff #1 and Staff #3 were corrected to include the missing information. The HR Manager and HR Assistant completed a review of Assisted Living employee files to verify that tuberculosis risk assessments are current and complete. If missing or incomplete risk assessments were identified, a new tuberculosis risk assessment was initiated. Tuberculosis risk assessment due dates were verified in the employee credentialing database. If a staff member does not have a current tuberculosis risk assessment on file, an alert is generated, and they will be removed from the schedule until one is completed. The HR Manager or her designee will audit five randomly selected staff files for the next three months to verify that they have current tuberculosis risk assessments. 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 #:	22VAC40-73-260-A
Description:	Based on record review and interview, 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: The record for Staff #3, hired 5/6/21 as a care manager, was reviewed during the inspection. Staff #3's record contained CPR certification, but no First Aid certification was included in the staff record. Facility staff confirmed that First Aid certification was not present in Staff #3's record.
Plan of Correction:	Staff #3 completed a first aid certification class on 2/11/22. The HR Manager and HR Assistant completed a review of Assisted Living employee files to verify that first aid certifications are current. No other discrepancies were found. First aid certification dates were verified in the employee credentialing database. If a staff member does not have a current first aid certification, an alert is generated, and they will be scheduled for a first aid certification class. The HR Manager or her designee will audit five randomly selected care 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 #:	22VAC40-73-560-E
Description:	Based on observation, the facility failed to ensure that resident records are kept in a locked area. Evidence: The facility's fourth floor wellness office was observed to be unlocked and unattended, shortly before 9:10 AM. Resident records were observed in an unlocked cabinet, in the wellness office.
Plan of Correction:	The door to the 4th floor wellness office was secured at the time of survey. The visiting nurse practitioner who left without securing the door was educated by the Wellness Nurse regarding the need to close and lock the door when the office is unattended. New signage stating that the door must be closed and locked when the office is unattended was posted on the door to the 4th floor wellness office. Refresher training was provided to staff working on the 4th floor regarding the need for the wellness office door to remain closed and locked when no one is in the office. Random observations will be conducted by the ALC or designee weekly for the next month, then bi-weekly for two months, to validate that the wellness office door is closed and locked when the office is unattended. The results of these random 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 #:	22VAC40-73-660-A
Description:	Based on observation, the facility failed to ensure that medications are stored in a manner consistent with current standards of practice. Evidence: The facility's fourth floor wellness office was observed to be unlocked and unattended, shortly before 9:10 AM. Several medications were observed on a desk in the wellness office.
Plan of Correction:	The door to the 4th floor wellness office was secured at the time of the survey. The visiting nurse practitioner who left without securing the door was educated by the Wellness Nurse regarding the need to close and lock the door when the office is unattended. New signage stating that the door must be closed and locked when the office is unattended was posted on the door to the 4th floor wellness office. Refresher training was provided to staff working on the 4th floor regarding the need for the wellness office door to remain closed and locked when no one is in the office. Random observations will be conducted by the ALC or designee weekly for the next month, then bi-weekly for two months, to validate that the wellness office door is closed and locked when the office is unattended. The results of these random 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: PRN Loperamide, ordered 4/22/21 for Resident #9, was not available for administration at the time of the medication cart audit. Resident #9's PRN Loperamide order calls for the resident to receive two 2mg capsules. Only one 2mg capsule was present, at the time of the medication cart audit. Facility staff reported that Resident #9 did not have any additional PRN Loperamide.
Plan of Correction:	The Loperamide ordered for resident #9 was refilled on 2/10/22. PRN medication orders were audited by the LPN Night Supervisor to verify that medications were available for administration. Medications that were not found or were nearing expiration were re-ordered from pharmacy. Staff who administer medications were assigned an online refresher training module regarding the process for reordering medications that are depleted. The RCD or her designee will audit five randomly selected PRN medication orders weekly for the next month, then bi-weekly for two months, to validate that medication is available for administration. The results of these random audits 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 #:	22VAC40-90-40-B
Description:	Based on observation, the facility failed to ensure that a criminal history record report is obtained on, or prior to, the 30th day of employment for each employee. Evidence: The background checks of new employees, hired since the last inspection, were observed during the inspection. The record for Staff #5, hired 8/25/21, contained a national background check that was completed in August 2021. Staff #5's record did not contain a criminal history record report, from the Virginia State Police, within 30 days of his hire. Staff #5's criminal history record report, from the Virginia State Police, was not completed until November 2021.
Plan of Correction:	The criminal history record report from the Virginia State Police for staff #5, hired on 8/25/21, was completed on 11/9/21 once access to the Virginia State Police system was obtained for the new HR Manager. The HR Manager and HR Assistant completed a review of Assisted Living employee files to verify that a criminal history record report was obtained from the Virginia State Police within 30 days of hire. No other discrepancies were found. In addition to the HR Manager, the HR Assistant was given access to the community?s account with Virginia State Police to run criminal history record reports. The HR Manager or her designee will audit new hire files for the next three months to verify that a criminal history report was obtained from the Virginia State Police within 30 days of hire. 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.