VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Reflections-A Senior Living Community
246 West Market Street
Leesburg, VA 20176
(703) 777-1971

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Oct. 13, 2020 and Oct. 15, 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 32.1 Reported by persons other than physicians 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:

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 monitoring inspection was initiated on 10/13/2020 and concluded on 10/15/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 11. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records, fire drill reports, staff work schedule, healthcare oversight report, annual fire and health inspection reports submitted by the facility to ensure documentation was complete. Criminal Background Checks of all staff hired since the previous inspection conducted on 6/23/2020 were reviewed. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility. 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 e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based upon a review of records, the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan. Evidence: The Individualized Service Plan (ISP) for Resident #2, dated 7/24/2020, did not include Hospice services that the resident is receiving and has been receiving since 5/18/2020.
Plan of Correction:	Hospice services were added to the Individualized Service Plan (ISP) for Resident #2. Resident Care Director (RCD) and/or designee will audit all current ISP's to make sure hospice and all additional services are included on the ISP. RCD and/or designee will use the medical records to update the ISP when hospice and other new services are added to resident's care. RCD and/or designee will review quarterly and on an as needed basis to ensure that hospice and all additional services are included on the ISP.