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: Oct. 20, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNES 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 22VAC40-80 THE LICENSING PROCESS

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10-20-22 from 9:55 a.m.- 4:30 p.m. 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: 28 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 3 Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 3 Additional Comments/Discussion: The following items were reviewed/observed during the inspection: facility documentation, facility postings, medication pass/physician?s orders/Medication Administration Records (MARs), lunch meal/menu, emergency food and water supply, and first aid kit. Residents and staff were also interviewed. 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 the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Kimberly Davis, Licensing Inspector at (804) 662-7578 or by email at Kimberly.M.Davis@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records the facility failed to ensure that each staff person shall annually submit the results of a tuberculosis (TB) risk assessment, documenting that the individual is free of tuberculosis in a communicable form 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 Staff # 3 (date of hire: 9-21-18) contained a TB assessment last dated 9-17-21. -Staff # 5 stated that the facility will ensure that each staff member?s TB assessment is up to date.
Plan of Correction:	Martha Jefferson House Director of Human Resources will assure TB screenings are completed annually for all staff and that documentation of the screenings is maintained in the staff chart. A chart audit will be completed monthly by the Human Resources Director in collaboration with the Nursing Supervisors and submitted to the DON by the 5th day of the following month to assure that all PPD forms are kept up to date. This process will implement with its first completion date due by the 21st of November; after which the due date will be the 5th of every month. Immediate action for Staff #3 includes an up-dated PPD screening completed 10/21/22 which has been placed in the staff members file.
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records the facility failed to ensure that each direct care staff member shall maintain current certification in first aid. Evidence: -The record for Staff # 2 (date of hire: 6-1-22) did not contain documentation of first aid certification. -Staff # 5 stated that the facility would ensure that the staff member obtain first aid certification.
Plan of Correction:	Martha Jefferson House Director of Human Resources will assure all nurse aides in Assisted Living are certified in a minimum of First Aid prior to hire which will be documented and submitted to the DON with new hire paperwork as a double check. HR Dept. will perform an audit of certifications quarterly to assure no out-dates and a course will be provided as needed for staff approaching expiration. Immediate action for Staff #2 has been completed on 10/21/22 as Certification was obtained by staff member and a copy of the record placed in the staff file. The next all-staff audit will be completed by November 30, 2022.
Standard #:	22VAC40-73-410-A
Description:	Based on a review of resident records the facility failed to ensure that upon admission, the assisted living facility shall provide an orientation for new residents and their legal representatives, including emergency response procedures, mealtimes, and use of the call system. If needed, the orientation shall be modified as appropriate for residents with cognitive impairments. Acknowledgment of having received the orientation shall be signed and dated by the resident and, as appropriate, his legal representative, and such documentation shall be kept in the resident?s record. Evidence: -The record for Resident # 1 (admit date: 7-11-22) did not contain acknowledgment of orientation. -Staff # 6 stated that the orientation was reviewed with the resident at admission but was not sure what happened to the acknowledgment form.
Plan of Correction:	Martha Jefferson House ALF will assure orientation for all new residents and their legal representatives within 24 hours of admission to include emergency response procedures, mealtimes, and use of the emergency call system. Acknowledgement of the orientation shall be signed and dated by the Admitting Nurse as well as the Resident and their legal representative and the documentation shall be kept in the resident?s chart. The orientation sheet for resident #1 was found filed inappropriately and has been restored to the resident chart. Immediate action includes re-education of all nursing staff to be completed by 11/15/22.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of staff records the facility failed to ensure that the rights and responsibilities of residents in assisted living facilities were reviewed annually with each staff person and that evidence of this review shall be the staff person's written acknowledgement of having been so informed, which shall include the date of review and shall be filed in the staff person?s record. Evidence: -The record for Staff # 3 (date of hire: 9-21-18) contained an annual review of resident rights last dated 3-15-19. No explanation was provided.
Plan of Correction:	Martha Jefferson House Director of Human Resources will assure that Resident Rights and Responsibilities will be reviewed annually with each staff person and evidence of this review shall be the staff person's written acknowledgement of having been so informed, which shall include the date of review and shall be filed in the staff person?s record. An audit will be performed by the HR department quarterly to ensure all staff files are up to date. Immediate action will include a current audit of staff files to be completed by November 30, 2022.
Standard #:	22VAC40-73-950-E
Description:	Based on an interview with staff the facility failed to ensure that it develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers with an emphasis placed on an individual?s respective responsibilities. The review shall be documented by signing and dating. Evidence: -Staff # 4 stated that the review of the facility?s emergency preparedness and response plan was last reviewed in June 2022, however, no documentation was provided.
Plan of Correction:	Martha Jefferson House will assure inclusion of the Emergency Preparedness Plan in all Human Resources Orientations, Volunteer Orientations and Resident Orientations. The Human Resources Director will require documentation of the completion for all new hires, and volunteers at the time of orientation and every 6 months and shall maintain the documentation in staff/volunteer files for review. Immediate action includes the completion of a current file audit for current records which should be complete by 11/15/22. The Director of Resident Services will review the Emergency Preparedness Plan with all new Residents and maintain documentation of the initial orientation and a review of said plan every 6 months. Documentation for Residents will be maintained in the Resident Chart. A current chart audit of Resident files will be completed by 11/30/22 to assure there are no missing records.
Standard #:	22VAC40-73-990-C
Description:	Based on an interview with staff the facility failed to ensure that at least once every six months 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 of a practice exercise for a resident emergency. -Staff # 4 stated that a practice exercise for a resident emergency had not been done in quite some time and the date was not known.
Plan of Correction:	Martha Jefferson House will maintain documented evidence of a practice exercise for resident emergency. DON and ADON will maintain records in the DON office documenting the specific exercise conducted, and a staff signature sheet indicating employee compliance every 6 months. Immediate action includes a Resident Elopement drill to be completed Nov. 11, 2022.