VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Morningside House of Leesburg
316 Harrison Street, SE
Leesburg, VA 20175
(703) 777-2777

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Jan. 6, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced complaint inspection was conducted on 1/6/23 in response to a complaint received by the licensing office on 12/9/22 regarding: Administration and Administrative Services, Admission, Retention, and Discharge of Residents, and Resident Care and Related Services. Resident records were observed. Violations were discussed and an exit meeting was held. 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-390-A
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that the resident agreement includes a description of all accommodations, services, and care that the facility offers and any related charges. Evidence: Resident agreements were observed during the inspection. The resident agreements; for Residents #1, #2, and #4; listed the care levels provided by the facility, but the care levels were not described. A signed level of care worksheet, that indicates the care necessary to meet each level, was not included in the records of Residents #1, #2, or #4 at the time of their admission.
Plan of Correction:	Residents #1, #2, and #4 had completed level of care worksheets that were reviewed and agreed to prior to admission by each resident with the lease agreements. The worksheets completed were not signed in addition to the lease agreement. Facility was not aware that the lease agreement itself did not fulfill the admission requirement for the description of services to be provided. ED, HWD or designee will audit all resident records to ensure that level of care worksheet is signed by the resident or resident representative along with the lease agreement. Facility will ensure the level of care worksheet is signed for future residents at the time of admission.
Standard #:	22VAC40-73-450-E
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that each individualized service plan (ISP) is signed by the resident or their legal representative. Evidence: Resident # 1's ISP, dated 11/7/22, was signed by the Director of Health and Wellness. The ISP was not signed by the resident or her legal representative. Resident #4?s record contained two ISPs, dated 2/8/22 and 3/4/22, but the ISPs were not signed by the resident or his legal representative.
Plan of Correction:	Residents #4's ISP was not signed by the resident or resident's legal representative. Facility will have the resident or resident representative sign this document for the resident record. ED, HWD or designee will audit all resident records to ensure resident current ISPs are signed by the appropriate resident or resident representative.