VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise Assisted Living of McLean
8315 Turning Leaf Lane
Mclean, VA 22102
(703) 734-1600

Current Inspector: Alexandra Roberts

Inspection Date: April 10, 2019 and April 11, 2019

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 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.

Technical Assistance:

A completed Renewal Application with an updated ALF Disclosure Statement (3/19) must be submitted prior to the expiration of the current license, if not already done. Applications and model forms may be obtained from the DSS website dss.virginia.gov.

Comments:

An unannounced renewal study was conducted from 8:30a.m. - 5:00p.m. on 4/10/19 and 9:00a.m. - 5:00p.m. on 4/11/19 and. At the time of entrance 83 residents were in care. The sample size consisted of ten resident records including two discharged resident records and five staff records. Three residents, two family members, staff and ancillary staff interviewed. Resident, staff, volunteer and pet records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection conducted on 4/18/2018 reviewed. Residents were observed eating breakfast and lunch and engaging in activities including exercise, craft shadow boxes, baking, live guitar with sing-a-long, and Daily Chronicles. Medication administration observed with two staff and medication carts observed for PRN medications. Building and Grounds observed. Violations and risk ratings reviewed during 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 703-895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on record review, facility failed to ensure that the comprehensive Individualized Service Plan (ISP) shall include a description of identified needs and date identified based upon the Uniform Assessment Instrument (UAI). Evidence: 8/8 residents' ISPs require a description of identified needs based upon the UAI. Resident #1's most recent UAI dated 1/1/2019 does not indicate incontinent of bowel and incontinent of bladder and most recent ISP dated 1/19/19 states "continent of bowel", "continent of bladder" and "require the use of briefs for continence management"; and UAI indicates Toileting requires Human Help Only/Supervision and ISP indicates "care needs to the bathroom will be provided by care managers", "need a walker for assistance to bathroom", "need a grab bar for assistance to bathroom", "am independent with Mechanical Help with assistance to the bathroom", "need standby assistance to the bathroom" and toileting is not specified on the ISP. Resident #2's most recent UAI dated 2/12/2019 indicates walking in not performed and most recent ISP dated 2/19/2019 states "I need a walker to assist with walking" and "I do not walk due to inability to walk on my own". Resident #3's most recent UAI dated 12/28/2018 does not indicate if resident is content of bowel and continent of bladder and most recent ISP dated 12/28/2018 indicates bowel and bladder "incontinence less than weekly" and "use of protective underwear". Resident #4's most recent UAI dated 11/5/2018 answers both no and yes for Bowel Needs Help and most recent ISP dated 11/06/2018 indicates bowel incontinence "I am continent of Bowel" and bladder incontinence "I am incontinent less than weekly", Encourage me to request assistance" and "I require the use of pads for my continent management." Resident #5's most recent UAI dated 2/25/2019 does not answer Bowel and Bladder Needs Help and most recent ISP dated 2/28/2019 indicates "experience bowel incontinence less than weekly" and "incontinent less than weekly" for bladder and "require the use of protective underwear". Resident #6's most recent UAI dated 2/18/2019 answers both no and yes for Bowel Needs Help and most recent ISP dated 2/18/2019 indicates "continent of bowel" and "bladder incontinence care needs will be provided by Sunrise care team". Resident #7's most recent UAI dated 4/8/2019 answers both no and yes for Bowel and Bladder Needs Help and most recent ISP dated 4/8/2019 indicates "when assisting with incontinence care" and bladder continent "I am continent of bladder" and "require the use of protective underwear"; and UAI indicates mobility is performed by others and ISP states "independent with my mobility." Resident #8's most recent UAI dated 11/13/2018 answers both no and yes for Bowel and Bladder Needs Help and most recent ISP dated 11/23/2018 indicates bowel incontinence "am continent with bowel" and bladder continence "assistance as needed or requested" and "usually only require the use of pads at night for my continence management".
Plan of Correction:	A. With respect to the specific residents/situation cited: The Resident Care Director, along with the Assisted Living Coordinator, will complete an updated ISP and UAI for the 8 residents, with a focus on continence needs, toileting assistance, mobility status and assistance, and assistive devices. B. With respect to how the facility will identify resident/situations with the potential for the identified concerns: The Resident Care Director, along with the Assisted Living Coordinator will review current resident UAIs and ISPs and verify the ISPs include a description of identified needs in regards to continence needs, toileting assistance, mobility status and assistance, and assistive devices; and date identified based upon the UAI. Issues identified will be addressed and resolved. C. With respect to what systemic measures have been put into place to address stated concern: The Resident Care Director, along with care coordinators, will be responsible for updating the UAI along with the ISP as changes in resident needs are identified, during Interdisciplinary Meetings that occur 2 to 3 times per month or as needed. During Monthly Wellness Visits, the designated coordinator will evaluate residents? UAI and ISP to verify that the focus areas interventions are accurate and current. The results of the updates, Wellness Visits, and the IDT meetings will be presented at the QAPI Meeting for 3 months. During and at the conclusion of each month, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. . D. With respect to how the plan of correction will be monitored: The Resident Care Director is responsible for confirming implementation and on-going compliance with the components of this Plan of Correction and addressing and resolving variances if they occur.
Standard #:	22VAC40-73-460-B
Description:	Based on record review, interview and observation, facility failed to ensure that care provision and service delivery shall be resident-centered to the maximum extent possible and shall include personalization of care and services tailored to the resident's circumstances and preferences. Evidence: Resident #6's most recent Individualized Service Plan (ISP) dated 2/18/2018 states "I have a companion daily who provides me assistance with dining. I prefer to have my companion provide me assistance with dining. My companion was assessed and approved by the RC. (Date initiated 01/04/2019.)" and interviews with staff and ancillary staff confirmed that resident's preference is have the Private Duty Aid (PDA) assist with feeding; and during observation of breakfast on 4/10/2019, Licensing Inspector observed PDA feeding breakfast to Resident #6 and then observed facility staff replace the PDA with the feeding assistance at that meal; and facility staff was observed assisting Resident #6 with feeding during lunch on 4/10/2019, breakfast on 4/11/2019, and lunch on 4/11/2019 while the PDA was observed seated across the room during each meal. Resident #5's most recent ISP dated 2/28/2019 states "my private companion, Rose, will be with me during the day" and the ISP indicates that mobility, wheeling and transfering assistance is "provided by Sunrise care team" and the companion is not identified on the ISP to perform assistance as observed by Licensing Inspector and confirmed by interview.
Plan of Correction:	A. With respect to the specific residents/situation cited: The Resident Care Director, along with the Assisted Living Coordinator, will complete an updated ISP and UAI for the 2 residents (Resident #5 and #6) with a focus on companion coverage and services, dining assistance and mobility assistance. B. With respect to how the facility will identify resident/situations with the potential for the identified concerns: The Resident Care Director, along with the Assisted Living Coordinator will review current resident ISPs and verify the ISPs are resident-centered and include personalization of care and services tailored to the resident?s circumstances and preferences, including companion coverage and services, dining assistance and mobility assistance. C. With respect to what systemic measures have been put into place to address stated concern: The Resident Care Director, along with care coordinators, will be responsible for updating the UAI along with the ISP as changes in resident needs are identified, during Interdisciplinary Meetings that occur 2 to 3 times per month or as needed, including a focus on resident-centered interventions and personalization of care. During Monthly Wellness Visits, the designated coordinator will evaluate residents? UAI and ISP to verify that the focus areas and interventions are resident centered and personalized. The results of the updates, Wellness Visits, and the IDT meetings will be presented at the QAPI Meeting for 3 months. During and at the conclusion of each month, the QAPI committee will re-evaluate and initiate necessary action or extend the review period. D. With respect to how the plan of correction will be monitored: The Resident Care Director is responsible for confirming implementation and on-going compliance with the components of this Plan of Correction and addressing and resolving variances if they occur.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. Evidence: 1/22 records reviewed did not contain a criminal record report obtained on or prior to the 30th day of employment. Staff #11 hired on 11/28/2018 and the criminal history report in record is dated 4/11/2019.
Plan of Correction:	A. With respect to the specific employee/situation cited: The Business Office Coordinator, or designee, completed a criminal background history report for staff #11. B. With respect to how the facility will identify omissions from employee records or potential for the identified timeframe concerns: The Business Office Coordinator, or designee, will review current employee records and verify the criminal history record was obtained and is in the record. The Business Office Coordinator, or designee, is responsible for applying for access to the Virginia State Police website to expedite VA background check process and timely receipts. C. With respect to what systemic measures have been put into place to address stated concern: The Business Office Coordinator or designee will perform audits of criminal background reports and findings monthly for 3 months, which will be presented at the QAPI Meeting for 3 months. During and at the conclusion of each month, the QAPI committee will re-evaluate and initiate necessary action, or extend the review period. D. With respect to how the plan of correction will be monitored: The Business Office Coordinator or designee will be responsible for confirming implementation and on-going compliance with the components of this Plan of Correction and addressing and resolving variances if they occur.