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

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.