VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Johnson Center at Falcons Landing
20535 Earhart Place
Potomac falls, VA 20165
(703) 404-5201

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Feb. 12, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Licensing Inspector (LI) reviewed changes to Standard 73-50-Disclosure.

Comments:

On 2/12/2020 Licensing Inspector (LI) conducted unannounced inspection in response to self-reported incidents. Reviewed resident records and toured the physical plant. Possible violations were discussed at the exit interview. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps 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 and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based upon a review of resident records, the facility failed to ensure that the comprehensive individualized service plan shall be completed within 30 days after admission and shall include the following: description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources. Evidence: The Uniform Assessment Instrument (UAI) completed on 10/4/19 for Resident #2 indicated that no help was needed with dressing, toileting, transferring, incontinence, and that mechanical help only was needed for mobility. The Individualized Service Plan (ISP), dated 11/15/19, indicated that Resident #2 needs mechanical help and human help with bathing, human help with dressing, mechanical help and human help with toileting, mechanical help with transferring, and mechanical help and human help with mobility.
Plan of Correction:	Resident #2 did not experience any harm as a result of the items identified in 22 VAC 40-73(6)-450 C. The Uniform Assessment Instrument (UAI) and Individualized Service Plan (ISP) for Resident #2 have been updated to reflect current information for dressing, toileting, transferring, incontinence, and mobility. All current resident's UAI's and ISP's will be reviewed for accuracy and personalization and will be updated as needed. UAI and ISP for new residents and reassessments will be audited monthly by the Director of Nursing (DON) or designee. Any noncompliance will be reported to the Quality Assurance (QA) committee for further recommendation. Nurse involved was reeducated regarding proper completion of ISP.
Standard #:	22VAC40-73-450-D
Description:	Based upon a review of resident records, the facility failed to ensure that when hospice care is provided to a resident, the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan. Evidence: The Individualized Service Plan (ISP) for Resident #2 was completed 11/15/19 and has not been updated to reflect admission to Hospice Care on 1/9/2020.
Plan of Correction:	Resident #2 did not experience any harm as a result of the items identified in 22 VAC 40-73-(6)-450-D. Individualized Service Plan (ISP) for Resident #2 has been updated to reflect admission to hospice care and coordinated plan of care and services that will be provided beginning 1/9/2020. Currently there are no other residents on hospice care. Any changes to ISP's will be reviewed for accuracy and personalization and will be updated as needed when resident care needs change, i.e. hospice care. Monthly audits will be conducted by the Director of Nursing (DON) or designee. Any noncompliance will be reported to the Quality Assurance (QA) committee for further recommendations.