VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise at Bluemont Park
5910 Wilson Boulevard
Arlington, VA 22205
(703) 536-1060

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: May 28, 2021

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.

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 5/28/2021 and concluded on 5/28/2021. The administrator was contacted by telephone for an entrance interview to initiate the inspection. The administrator reported that the current census was 105. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed five resident records and five staff records. Criminal record checks and sworn statements of all staff hired since issuance of license and other documentation submitted by the facility was reviewed to ensure documentation was complete. Exit interview was conducted with the administrator on 6/07/2021. Information gathered during the inspection determined non-compliance(s) 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, 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s), and 4) date that that plan of correction will be completed. Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on record review, facility failed to ensure that a written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them shall be included on the comprehensive Individualized Service Plan (ISP). Evidence: Resident #1's ISP dated 5/05/2021 does not document the resident's Physical Therapy Services ordered 5/07/2021.
Plan of Correction:	A.) With respect to the specific resident/situation cited: The ISP for resident #1 was updated to include services to be provided, who will provide the services, and the frequency of those services. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Resident Care Director (RCD) or designee completed an audit of all residents? ISPs who are currently receiving outpatient rehabilitation services. ISPs updated as needed. C.) With respect to what systemic measures have been put into place to address the stated concern The RDC completed training with the Wellness Nurses, the Assisted Living Coordinator and the Resident care Coordinator on ISP requirements and compliance. The RCD/Designee will monitor ISP?s for residents with new/continuing orders for outpatient rehabilitation services for 3 months and report outcome to QAPI committee. D. With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices. The ED or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment. Evidence: 8/105 Staff records documented Sworn Statements that were not completed. Sworn Statements signed by the applicants for Staff #3 dated 3/31/2021, Staff #27 dated 4/05/2021, Staff #65 dated 4/05/2021, Staff #68 dated 3/30/2021, Staff #76 dated 4/08/2021 and Staff #87 dated 4/01/2021 did not document an answer to the question "have you ever been convicted of a law violation"; and Staff #101's SS was not signed and dated by the applicant; and Staff #28's SS was dated 6/25/2021 after the date of this inspection.
Plan of Correction:	A.) With respect to the specific resident/situation cited: Team members #3, #27, #65, #68, #76 and #87 answered the overlooked question, ?have you ever been convicted of a law violation?, on their sworn statement. Team member #101 signed and dated their sworn statement. Team member #28 completed a new sworn statement and dated accordingly. Corrections that were completed on existing sworn statement forms were initialed by the team member. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director (ED) or designee to conduct an audit of all current team member sworn statements to validate that they have been filled out completely, signed and dated appropriately. Any sworn statements found that are not completed appropriately will be addressed and corrected. C.) With respect to what systemic measures have been put into place to address the stated concern: Retraining completed with the HR Representative over what must be filled out on the sworn statement. Going forward, prior to a new team member?s first day, the Human Resource Representative or designee reviews the required new hire paperwork, including the sworn statement. The sworn statement will be reviewed to verify that it has been completed correctly, signed, and dated. For the next 3 months all new team members that are hired for the community, the Executive Director (ED/Administrator) or designee will review the required new hire documents, including the sworn statements. The sworn statements will be reviewed to verify that the form was fully completed with all questions answered, signed, and dated appropriately. D.) With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices. The ED or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
Standard #:	22VAC40-90-30-C
Description:	Based on record review, facility failed to ensure that any person making a maerially false statement on the sworn statement or affirmation shall be guilty of a Class 1 misdemeanor. Evidence: 4/105 employees documented on their Sworn Statements an answer of "no" to the question "have you ever been convicted of a law violation(s)" and their Criminal History Record (CHR) documented a conviction for each staff: Staff #41's SS dated 3/22/2021 and CHR dated 3/22/2021, Staff #77's SS dated 3/23/2021 and CHR dated 3/22/2021, Staff #79's SS dated 3/23/2021 and CHR dated 3/22/2021 and Staff #85's SS dated 3/26/2021 and CHR dated 3/22/2021 document conflicting information.
Plan of Correction:	A.) With respect to the specific resident/situation cited: Team members #41, #77, #79 and #85 completed new sworn statement forms and completely and correctly answered the question ?have you ever been convicted of a law violation?. Answers no longer conflict with the results on their Criminal History Record. B.) With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director (ED) or designee to conduct an audit of all current team member sworn statements to validate that they have been filled out correctly and do not conflict with results on the Criminal History Record. Any sworn statements found that are not correct will be addressed and corrected. C.) With respect to what systemic measures have been put into place to address the stated concern: Retraining completed with the HR Representative over what must be filled out on the sworn statement. Going forward, prior to a new team member?s first day, the Human Resource Representative or designee reviews the required new hire paperwork, including the sworn statement. The sworn statement will be reviewed to validate that it has been filled out correctly and does not conflict with results on the Criminal History Record. For the next 3 months all new team members that are hired for the community, the Executive Director (ED/Administrator) or designee will review the required new hire documents, including the sworn statements. The sworn statements will be reviewed to verify that the form was fully completed and that the answers do not conflict with the Criminal History Record. D. With respect to how the plan of correction will be monitored: During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices. The ED or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.