VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Morningside House of Leesburg
316 Harrison Street, SE
Leesburg, VA 20175
(703) 777-2777

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Nov. 18, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION

Comments:

An unannounced complaint inspection was conducted on 11/18/22 in response to complaints received by the licensing office on 10/31/22 and 11/7/22 regarding Staffing and Supervision, and Resident Care and Related Services. Facility documentation and resident records were observed. The complaint was determined to be 'valid,' as a preponderance of evidence supported the allegations. 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 five business 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-280-A
Complaint related:	Yes
Description:	Based on documentation and interview, the facility failed to have staff adequate in knowledge, skills, and abilities and sufficient in numbers to provide services to attain and maintain the physical, mental, and psychosocial well-being of each resident as determined by resident assessments and individualized service plans, and to ensure compliance with this chapter. Evidence: On 34 occasions, there were two staff members that worked during the 10PM - 6 AM shift (10/15/22 - 11/17/22). Facility staff reported that there was no documentation of staff members refusing a break period during that timeframe. Resident documentation, reviewed during the inspection, indicated that there are at least two residents (Resident #1 and Resident #2) that require two staff members for ADL assistance. During staff member break periods, the facility would not have a sufficient amount of staff members to provide resident assistance when only two staff members are on duty. Facility punch detail reports were observed and only one staff member was documented as being present on 10/30/22 (from 4:45 AM until 6 AM) and 11/6/22 (from 10 PM until 11:15 PM).
Plan of Correction:	Two staff members are on duty from 10p-6a nightly. Resident #1 and Resident #2 require two staff members to assist with ADLs. The number of staff members present during this time would not allow for staff to take a break during their shift and still have the number of required staff members to assist with the level of care needed. Facility will immediately implement a change to the start time of a day shift staff member to allow for an additional staff member to be on site during the 10p-6a shift for coverage during a 30-minute break during this time period. Staff members have been counseled as to the requirement to remain on duty until additional staff members are on duty. ED and HWD will review census and acuity levels monthly and facility will add additional staff members to shift as needed to ensure all resident care needs are met.
Standard #:	22VAC40-73-290-A
Complaint related:	Yes
Description:	Based on documentation, the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Any absences, substitutions, or other changes shall be noted on the schedule. Evidence: Facility schedules for October and November were observed. The facility schedules were not updated to include all substitutions involving Staff #1 and Staff #2.
Plan of Correction:	Staff schedule was not completely updated to reflect staff coverage made for absences. Wellness Coordinator has been counseled as to the importance of having correct documentation regarding schedule changes as they occur. Wellness Coordinator will make all corrections to the posted schedule in a timely manner so the schedule is available to the licensing agency at any time it is requested. HWD or designee will review staff schedule bi-weekly to ensure schedule reflects staff members that were on duty for each shift.