VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Pivotal Assisted Living
6006 Hibbling Avenue
Springfield, VA 22150
(301) 503-1706

Current Inspector: Alexandra Roberts (804) 845-6956

Inspection Date: April 24, 2024

Complaint Related: No

Comments:

Type of Inspection: Renewal Inspection Date of Inspection: April 24, 2024 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: 1 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed residents eating lunch, 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 inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee 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 within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. 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 #:	22VAC40-73-260-A
Description:	Based on record reviewer, facility failed to ensure that direct care staff members have a current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute. Evidence: Staff #1 was certified by AHS American Health Service & Staff #2 certified by EMS inc.
Plan of Correction:	Employees CPR certification not recognized by Virginia as an approved vendor for CPR: Corrective action taken- Informed all staff impacted (4) requesting all employees obtain CPR/First Aid Certification from an approved CPR vendor. Each employee must complete within 30 days for continued employment.Provided information to a local American Heart Association Instructor to provide education and training. Employer will reimburse after successful completion of class. Preventative- Will ensure all employees hired moving forward have CPR/First Aid training by an approved Virginia Vendor.
Standard #:	22VAC40-73-650-C
Description:	Based on record review, the facility failed to have the oral order charted by the individual who takes the order nor was the oral order reviewed and signed by a physician or other prescriber within 14 days. Evidence: LI reviewed Resident #1 chart and the Licensed health professional obtained updated orders orally for the residents 2 prescriptions (Atorvastatin 40mg & Memantine 10mg) but failed to chart the oral order and failed to have the order reviewed then signed by the physician/prescriber within 14 days.
Plan of Correction:	Physician Order not signed in 14 days: Correction Action Taken- Called physician office sent email via docusign requesting a signature on 4/25/24. Preventative: Perform Chart Audits monthly. Implement process for follow up calls to obtain signature if not received by day 3, day 7, and day 10, day 14
Standard #:	22VAC40-73-680-C
Description:	Based on record review, medication were administered later than one hour after facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: On several dates (04/19/24, 04/18/24,04/08/24, & 04/08/24) the residents #1 9am medication (Memantine 10mg for Dementia) was taken more than 1 hour after the allotted time frame. 4/21/24 the 9am medication was given at 10:43am.
Plan of Correction:	Medications administered outside 2 hour window: Provided individual staff education to employees regarding medication administration times and 2 hour window to pass medications ( 1 hour before or 1 hour after). Will include information in staff education for a month. Preventative: Audit Charts to verify medications are being given at the correct time.
Standard #:	22VAC40-73-680-H
Description:	Based on record review, the facility failed to document on the medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. Evidence: Staff failed to document at the time the medication was administered for medications for several dates: 9am 04/24/24 - Memantine 10mg 9am 04/23/24 - Memantine 10mg 8pm 04/22/24 - Atorvastatin 40mg 8pm 04/22/24 - Memantine 10mg
Plan of Correction:	. Documentation of reason why medications were administered late: Provided individual staff education to employees on the importance of documenting rationale and reasons for orders not completed or administered. Reviewed Missed Medication Policy. This topic will also be a discussion topic in monthly education. Preventative: Implemented a check list for each shift to follow to ensure all items are documented and completed at the end of shift.