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: Nov. 6, 2023

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 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 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: 11-6-23 from 9:34 a.m.-3:20 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: 32 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: 3 Number of interviews conducted with staff: 4 Additional Comments/Discussion: The following items were also reviewed/observed during the inspection- facility documentation, facility postings, first aid kit, lunch meal/menu, resident activities, medication pass, physician?s orders, and Medication Administration Records (MARs). An exit meeting was 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

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on a review of staff records the facility failed to ensure that at least two of the required hours of staff training shall focus on infection control and prevention. Evidence: The record for Staff # 2 (date of hire: 3-25-14) did not contain documentation of at least two hours of infection control and prevention training.
Plan of Correction:	Martha Jefferson House HR Director has incorporated an additional two hours of Relias Infection control and prevention training for all staff members due by December 31, 2023, and will repeat annually.
Standard #:	22VAC40-73-950-E
Description:	Based on a review of facility documentation the facility failed to ensure that it shall develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities. The review shall be documented by signing and dating. The orientation and review shall cover responsibilities for: 1. Alerting emergency personnel and sounding alarms; 2. Implementing evacuation, shelter in place, and relocation procedures; 3. Using, maintaining, and operating emergency equipment; 4. Accessing emergency medical information, equipment, and medications for residents; 5. Locating and shutting off utilities; and 6. Utilizing community support services. Evidence: The facility was unable to provide documentation of a semi-annual review of the emergency preparedness and response plan for all staff, residents, and volunteers, with emphasis placed on an individual's respective responsibilities.
Plan of Correction:	The HR Director in coordination with the Director of Residents Services will assure that all staff members, volunteers, and residents review the Emergency Preparedness Plan, to be completed: 12/1/23. The Emergency Preparedness Plan will be reviewed every quarterly with all staff, residents, and volunteers with the emphasis on individual?s respective responsibilities. A quarterly audit will be completed for the next 6 months.
Standard #:	22VAC40-73-980-C
Description:	Based on observation the facility failed to ensure that first aid kits shall be checked at least monthly to ensure that all items are present and items with expiration dates are not past their expiration date. Evidence: The facility?s first aid kit that was last checked on 10-11-23 contained antiseptic ointment with an expiration date of January 2023.
Plan of Correction:	First aid kits will be checked monthly to ensure all items are included and are not expired. The monthly audit tool will be modified to include a column for staff to add the expiration date of each applicable item. DON will perform random audits to ensure accuracy of monthly checks.
Standard #:	22VAC40-73-990-C
Description:	Based on a review of facility documentation 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 resident emergencies.
Plan of Correction:	A resident emergency drill will be completed quarterly. There will be an in-service sheet completed by all participating employees. The DON will keep records of these drills.