VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Martha Jefferson House
1600 Gordon Avenue
Charlottesville, VA 22903
(434) 293-6136

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: March 25, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 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 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.

Comments:

An unannounced monitoring inspection was conducted by the licensing inspector on March 25, 2022. A census of 31 residents was reported. A sample of 6 resident and 3 staff records were reviewed. The following items were reviewed/observed: facility postings, lunch meal/menu, activity schedule, facility documentation, a tour of the facility, emergency food and water supply, and medication pass/physician's orders/Medication Administration Records (MARs). Residents and staff were also interviewed. The violations cited are identified in this report. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) 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 during this inspection. I can be reached at Kimberly.M.Davis@dss.virginia.gov or (804) 662-7578.

Violations:

Standard #:	22VAC40-73-50-B
Description:	Based on a review of resident records the facility failed to ensure that each record contained a written acknowledgement of the receipt of the disclosure statement by the resident or his legal representative. Evidence: The record for Resident # 3 and Resident # 4 did not contain written acknowledgment by the resident or his legal representative of the receipt of the disclosure statement. The DON attempted to locate the documents but was unable to provide them.
Plan of Correction:	Our Marketing/Admissions director in collaboration with nursing will monitor all new resident charts to be certain the documents are in place in a timely manner. Nursing Supervisors will audit the AL resident charts every three months to assure that the documents are in each chart and are up to date. (Note: The disclosure statements in question were found in the respective resident charts but were filed in the wrong section.)
Standard #:	22VAC40-73-320-B
Description:	Based on a review of resident records the facility failed to ensure that a risk assessment for tuberculosis (TB) was completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: The record for Resident # 4 contained a TB screening last dated 10-10-2020. The DON was unable to locate a more recent document when asked.
Plan of Correction:	TB screenings must be completed annually for all residents of Martha Jefferson House. A chart audit will be completed monthly by supervisory staff and submitted to the DON by the 5th day of the following month to assure that all PPD forms are kept up to date.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident records the facility failed to ensure that individualized service plans (ISPs) shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. Evidence: The record for Resident # 4 contained an ISP last dated 2-2-2021. The Director of Nursing (DON) stated that a care plan meeting was scheduled for next week for the resident.
Plan of Correction:	Resident #4 care plan (ISP) update completed 3/29/2022. Resident Care Plan will be audited every 3 months by supervisory staff to assure no additional omissions.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities were reviewed annually with each resident or his legal representative or responsible individual and each staff person and that evidence of this review shall be the resident's, his legal representative's or responsible individual's, or staff person's written acknowledgement of having been so informed, which shall include the date of review and shall be filed in the resident's record. Evidence: -The record for Staff # 1 contained written acknowledgement of an annual review of the rights and responsibilities of residents in assisted living facilities last dated 10-5-2020. -The record for Staff #2 contained written acknowledgement of an annual review of the rights and responsibilities of residents in assisted living facilities last dated 3-7-19. -The record for Resident # 4 contained written acknowledgement of an annual review of the rights and responsibilities of residents in assisted living facilities last dated 8-17-2020. -Staff was unable to locate/provide current documents when asked.
Plan of Correction:	The Social Services Coordinator (SSC) shall be responsible for the initial review and signing of the rights and responsibilities documentation with all new admissions within the first 48 hours of living in the assisted living facility. The SSC shall further conduct a yearly update with all residents of the assisted living facility ensuring that a signed copy of the annual review is placed in the resident record.
Standard #:	22VAC40-73-990-C
Description:	Based on a review of facility documentation the facility failed to document at least once every six months that all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Evidence: The facility was unable to provide documentation for a practice exercise for a resident emergency but staff stated that the last practice exercise was conducted in December 2021.
Plan of Correction:	The DON will ensure that practice exercises for resident emergencies are documented every six months.