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Ashby Ponds, Inc.
21160 Maple Branch Terrace
Ashburn, VA 20147
(571) 291-6210

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: May 13, 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
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.

Technical Assistance:
LI suggested that the facility ensure that medication management procedures the facility are currently performing also be documented in their written medication management policy.

Comments:
An unannounced monitoring study was conducted on 5/13/19 At the time of entrance 96 residents were in care. The sample size consisted of ten resident records, five staff records, two volunteer records, and four individual interviews. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 4/26/18 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including strength training, coloring, and sorting socks. Medication administration was observed. An exit interview was held and possible violations were discussed. The administrator signed the acknowledgement of inspection form. 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 #: 22VAC40-73-250-D
Description: Based upon review of records, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence 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. Based upon a review of records, the facility failed to ensure that each staff person required to be evaluated shall annually submit the results of a 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 initial tuberculosis assessments for the following: Staff #3 (hire date 4/1/19); Staff #4 (hire date 2/4/19); and Staff #5 (hire date 2/4/19) did not document the "absence of tuberculosis in a communicable form." The annual tuberculosis assessments for the following: Staff #1 (hire date 7/7/14) and Staff#2 (hire date 4/2/18) did not document that the "individual is free of tuberculosis in a communicable form."

Plan of Correction: 1. TB screenings previously completed for staff members #1, #2, #3, #4, and #5 cannot be fixed. However, as of 3/20/19, provider has signed acknowledgement that employees are free of tuberculosis. 2. HR Manager will complete 10 random staff audits X3 months to ensure documentation in within policy and DSS regulation. HR manager has provided education to Employee Health providers on regulation and policies to ensure there is documentation stating that individuals are free from TB. 3. HR Manager or designee will monitor all auditing and report findings outside of policy and regulation to our monthly QAPI meeting. If further findings are found, QAPI committee will reeducate and complete further audits. 4. Date to be corrected 6/17/19

Standard #: 22VAC40-73-680-C
Description: Based upon medication administration observation and a review of medical records, the facility failed to ensure that medications shall be administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals. Evidence: According to the Medication Administration Records (MARS) Resident #5 is to receive Pradaxa 150mg cap at 8 am and 8 pm. On May 13, 2019, a member of the inspection team observed Resident #5 being administered Pradaxa at 10:14 am.

Plan of Correction: 1. Provider was notified for late administration of medication for resident #5 on 5/13/19. Staff education on medication administration policy was provided to staff member # 2 on May 14, 2019. 2. A 100% audit for all medication administered on 5/30/19 will be completed to ensure medications are administered within one-hour parameter. Wellness manager or designee will complete monthly audit of 10 residents? X 3 months to ensure medications are administered within medication administration Policy and DSS regulations. 3. Wellness Manager or designee will ensure completion of 100% audit of medications given for 5/30/19 and monthly audits of medication administration policy moving forward. All findings outside of policy and regulation will be reported to our monthly QAPI meeting. If further findings are found, QAPI committee will reeducate and complete further audits. 4. Date to be corrected 6/17/19

Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.

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