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: May 22, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 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

Technical Assistance:

N/A

Comments:

Type of Inspection: Monitoring Inspection Date of Inspection: May 22 2024 from 9:15amam ? 6pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 47 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: The LI observed medication administration, residents eating lunch and going on a walk and participating in other activities. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the initial inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The applicant has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to maintain future compliance with applicable standard(s) or law. If the applicant 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 should the facility be issued a license to operate. 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 a licensed facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-650-C
Description:	Based on record review and staff interview, the facility failed to ensure that Physician's or other prescriber's oral orders are reviewed and signed within 14 days. Evidence: 1. Resident 2 had verbal order taken via nurse for hospice on 04/22/24 at 3pm. 2. Resident 2?s hospice order did not have physician signature within 14 days as observed on 5/22/24. 3. Staff 5 confirmed no signature on order.
Plan of Correction:	A. With respect to the specific resident/situation cited: Hospice provider was immediately contacted to send someone within 24 hours to sign order for singular Resident. B. With respect to how the facility will identify residents/situations for the identified concerns: Whole house audit conducted by Resident Care Director for all current Hospice Residents in Community to verify if there were any other verbal orders without signature outside of fourteen (14) days. There were no orders outside of the timeline. C. With respect to what systemic measures have been put into place to address the stated concern: Verbal order log created for wellness office to document timeline for signatures for verbal orders. Resident Care Director and / or Designee with review at least three days a week and report daily in morning meeting notes for orders older than seven (7) days. Resident Care Director and / or designee will educate all nurses by July 15, 2024, verbal order log procedure and that physician orders must be signed within fourteen (14) days; and that this process will be part of new hire, floor orientation. Administrator will distribute a letter to all contracted Hospice partners regarding their obligation for documentation and include a copy for all future Hospice services with Residents. D. With respect to how the plan of correction will be monitored: Compliance at-risk orders (greater that seven (7) days will be reported in morning meeting to utilize Interdisciplinary Team (IDT) and line staff to encourage awareness issue to respective Hospice personnel on site. The Resident Care Director and / or designee will report compliance to quarterly Quality Assurance Meeting. After two (2) consecutive quarters of the verbal orders from Hospice in compliance, the Resident Care Director may reduce oversight to a routine task versus daily report. Item added to Quality Oversight Review and ad hoc regional staff compliance rounds. The Administrator is responsible for confirming the implementation and compliance of this POC and addressing and resolving any variance that may occur.
Standard #:	22VAC40-73-980-A
Description:	Based on record review and staff interview, the facility failed to ensure a complete first aid kit is on hand without expired items and all items. Evidence : 1. First aid kit on hand had expired antiseptic wipes (expired 11/2019 & 02/2017), No assorted gauze, plastic bags or hand cleaner within the kit. 2. Staff 6 confirmed first aid kits have not been updated.
Plan of Correction:	A. With respect to the specific resident/situation cited: Upon discovery, first aid kit was replaced and updated with updated supplies. Community did note that the Community shares a hallway with owned Skilled Nursing Facility with ample routine first -aid supplies and crash cart and all items in first aid kit are part of community standard supply. B. With respect to how the facility will identify residents/situations for the identified concerns: A twelve (12) month inventory validation and inspection checklist will be attached to the required first aid kits and inspected monthly. C. With respect to what systemic measures have been put into place to address the stated concern: Inventory validation and inspection added to Wellness nurse monthly checklist. Resident Care Director and/or Designee will add inspection of the inventory and validation form monthly. Resident Care Director and / or designee will educate all nurses on the inspection check list process by July 15, 2024. D. With respect to how the plan of correction will be monitored: Resident Care Director and / or Designee will report to the Administrator before the month end that the kits are compliant. Signed Attestations will be submitted quarterly to Quality Assurance meetings. Upon two (2) consecutive quarters of 100% compliance with inspection reviews by Resident Care Director and / or Designee, significant compliance will have been determined; and quality assurance reporting will not be required. The Administrator is responsible for confirming the implementation and compliance of this POC and addressing and resolving any variance that may occur.
Standard #:	22VAC40-73-980-C
Description:	Based on record review and staff interview, the facility failed to ensure first aid kits are checked monthly. Evidence: 1. Staff 5 stated that the person that used to check the first aid kits left in 2017 and that the duty was never delegated to anyone to complete after that date. 2. Staff 5 & 6 confirmed the facility has not checked the first aid kit at least monthly.
Plan of Correction:	A. With respect to the specific resident/situation cited: Upon discovery, first aid kit was updated with supplies and inspected by Administrator and Resident Care Director for compliance. B. With respect to how the facility will identify residents/situations for the identified concerns: A twelve (12) month inventory validation and inspection checklist will be attached to the required first aid kits and inspected monthly. C. With respect to what systemic measures have been put into place to address the stated concern: Inventory Validation and Inspection added to Wellness nurse checklist. Resident Care Director will add inspection of the inventory and validation form monthly. Resident Care Director and / or designee will educate all nurses on the inspection check list process by July 15, 2024.