VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Virginian
9229 Arlington Boulevard
Fairfax, VA 22031
(703) 385-0555

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Sept. 30, 2020

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 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:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 9/30/20 and concluded on 10/02/20. The director of assisted living was contacted by telephone to initiate the inspection. The director reported that the current census was 73. The inspector emailed the director a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records, medication administration records, local fire and health inspections, and other documentation submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions. Evidence: The record, for Resident #4, contained an order for Simethicone, dated 1/28/20. The order calls for Resident #4 to receive Simethicone every six hours. Resident #4's medication administration record (MAR) stated that the medication was not available for the midnight administration on 9/29/20.
Plan of Correction:	The nursing staff responsible for missing the administration of the medications noted, were re-educated on the process of timely ordering, refilling, and administration of prescribed medications. The training included the process for obtaining new and refill medications from the pharmacy, as well as the protocol to follow when a medication has not been delivered on time. Director of Assisted Living, or designee will conduct quarterly random audits of eMARs to ensure all medications are available and administered as prescribed. Director of Assisted Living, or designee will provide training/re-education to all RN, LPN, and RMAs about the process for ordering and refilling medications with our pharmacy, as well as the process to be followed if a medication is not delivered in time for scheduled administration.
Standard #:	22VAC40-90-40-B
Description:	Based on documentation and interview, the facility failed to obtain a criminal history record report, from the Department of State Police, within 30 days of hiring an employee. Evidence: The record of Staff #3, hired 11/25/19, was reviewed during the inspection. The record contained a criminal record check that was provided by a private company. Staff #3's record did not contain a criminal history record report from the Department of State Police. Facility staff confirmed that the criminal history record report was unavailable, at the time of the inspection.
Plan of Correction:	Criminal History Record Reports, from the Department of State Police, have been obtained for identified staff member, and filed in their file. Director of Assisted Living, or designee is conducting audit of new employees hired in the last 12 months (September 2019 to present), to ensure Criminal History Record Reports have been obtained and filed in employee file. Director of Assisted Living, or designee will review each new employee record within 30 days of hire, to ensure Criminal History Record Reports are present in file. Director of Assisted Living, or designee will conduct random quarterly audits to ensure continued compliance.