VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Renaissance of Annandale
7112 Braddock Road
Annandale, VA 22003
(703) 256-2525

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Aug. 9, 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 22VAC40-90 Background Checks for Assisted Living Facilities

Technical Assistance:

Please note: Some of the computer generated staff Sworn Disclosure Statements do not indicate a yes/no answer to the questions. Please review to ensure consistency.

Comments:

An unannounced monitoring inspection was conducted on 8/9/19. At the time of entrance 37 residents were in care. The sample size consisted of six resident records, three staff records and two individual interviews. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 4/9/19 were reviewed. Residents were observed eating lunch and and engaging in activities including current events, exercise and arts and crafts. Medication administration was observed. Violation notice issued, risk ratings reviewed and exit interview held. 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 703-479-4708 or contact me via e-mail at lynette.storr@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Facility failed to ensure that prior to his admission to a safe, secure environment, the resident shall have been assessed by an independent clinical psychologist licensed to practice in the Commonwealth or by an independent physician as having a serious cognitive impairment due to a primary psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. Evidence: Resident #2 was admitted on 6/3/19. The physician's assessment of cognitive impairment did not include the required assessment of cognitive functions, thought and perception and mood/affect. The assessments of behavior/psychomotor, speech/language and appearance were indicated as attached however the attachment could not be found.
Plan of Correction:	a. Corrective action for Resident #2 listed in the deficiency: ? Once the deficiency was noted by the surveyor, the Resident Services Director contacted the resident?s physician. Resident #2 assessment forms were updated immediately by the resident?s physician and the resident?s chart was updated. b. Steps taken to identify other residents? physician?s paperwork is complete: ? The Resident Services Director, Executive Director, as well as a Governing Authority Representative will complete a full admission document audit ensure all Admission physician documentation is thoroughly completed. To be completed by 8/23/19. c. Measures, Systems or changes put in place to ensure this deficiency will not reoccur: ? All new admission and readmission documentation will be examined, in order, by the Sales and Marketing Director, the Executive Director, and the Resident Services Director prior to admission to verify that all documents are complete in its entirety for assurance of continuity of care. ? This deficiency will be reviewed during facility monthly Quality Assurance Meetings with oversite by Governing Authority Representative. ? This deficiency will be reviewed during facility monthly Quality Assurance Meetings with oversite by Governing Authority Representative.
Standard #:	22VAC40-73-220-A
Description:	Facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the following applies: The direct care or companion services provided by private duty personnel to meet identified needs shall be reflected on the resident's individualized service plan. Evidence: Resident #5 's ISP does not include the specific services that the private duty aid provides.
Plan of Correction:	a. Corrective action for resident #5 listed in this deficiency: ? Once the deficiency was noted by the surveyor, the resident?s Individualized Service Plan of resident #5 was immediately reviewed and updated by the Resident Services Director to include the specific services provided by the private duty personnel. b. Steps taken to identify other residents that have Private Duty Personnel to ensure they have these concerns addressed: ? The Resident Services Director, Executive Director, and the Governing Authority representative will perform a full Individualized Service Plan audit of those residents with Private Duty Personnel to verify that the services provided is up to date. To be completed by 8/23/2019. c. Measures, Systems or changes put in place to ensure this deficiency will not reoccur: ? Upon any changes to Private Duty Personnel services, the Resident Services Director will immediately update the resident?s Individualized Service Plan to reflect the service to be provided by the Private Duty Personnel. Once the Individualized Service Plan is updated, the Executive Director will then sign off on the plan as updated and complete. ? This deficiency will be reviewed during facility monthly Quality Assurance Meetings with oversite by Governing Authority Representative.
Standard #:	22VAC40-73-320-A
Description:	Facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: A statement that specifies whether the individual is or is not capable of self-administering medication. Evidence: Resident #2's admission physical examination dated 5/31/19 does not include a statement that specifies whether the individual is or is not capable of self-administering medication. Resident #4's admission physical examination dated 4/29/19 does not include the resident's height, weight and blood pressure.
Plan of Correction:	a. Corrective action for resident #2 listed in this deficiency: ? Once the deficiency was noted by the surveyor, the Resident Services Director contacted the resident?s physician. Resident #2 and Resident #4 Admission Physical Examinations were updated immediately by the resident?s physician and the resident?s chart was updated. b. Steps taken to identify other resident charts to ensure they do not have this deficiency: ? The Resident Services Director, Executive Director, as well as a Governing Authority Representative will complete a full Admission Physical Examination document audit ensure all Admission physician documentation is thoroughly completed. To be completed by 8/23/19. c. Measures, systems or changes put in place to ensure this deficiency will not reoccur: ? All new admission and readmission documentation will be examined, in order, by the Sales and Marketing Director, the Executive Director, and the Resident Services Director prior to admission to verify that all documents are complete in its entirety for assurance of continuity of care. ? This deficiency will be reviewed during facility monthly Quality Assurance Meetings with oversite by Governing Authority Representative.
Standard #:	22VAC40-73-380-A
Description:	Facility failed to ensure that prior to or at the time of admission to an assisted living facility, the following personal and social information on a person shall be obtained: Date of admission Evidence: Resident #4's admission date is not available in the resident's record.
Plan of Correction:	Corrective action for Resident #4?s admission date deficiency ? Once the deficiency was noted by the surveyor, the Executive Director immediately updated Resident #4 record to reflect the admission date as verified by the Business Office Manager on Resident Tracking Report. b. Steps taken to identify any other residents? charts having deficiency ? The Resident Services Director, Executive Director, as well as a Governing Authority Representative will complete a full resident record audit to ensure all resident personal and social information is on the residents record. To be completed by 8/23/19. c. Measures, systems or changes put in place to ensure this deficiency will not reoccur: ? All new admission documentation will be examined, in order, by the Sales and Marketing Director, the Executive Director, and the Resident Services Director prior to admission to verify that all documents are complete in its entirety including admission date. ? This deficiency will be reviewed during facility monthly Quality Assurance Meetings with oversite by Governing Authority Representative.
Standard #:	22VAC40-73-440-D
Description:	Facility failed to ensure that for private pay individuals, the assisted living facility shall ensure that the uniform assessment instrument is completed as required by 22VAC30-110. Evidence: Resident #5's UAI dated 6/27/19 was completed by an employee of the facility and was not signed by the Executive Director or Designee.
Plan of Correction:	a. Corrective action for Resident #5?s UAI listed in this deficiency: ? Upon identification of the deficiency by the surveyor, the Executive Director immediately reviewed Resident #5?s Uniform Assessment Instrument by reviewing the exam and then signing it for approval of appropriateness. b. Steps taken to identify other resident charts to ensure they do not have this deficiency: ? The Executive Director will audit all of the resident?s records to verify that all Uniform Assessment Instruments are appropriate and up to date with current information as well as contain the Executive Directors signature. To be completed by 8-23-19 c. Measures, systems or changes put in place to ensure this deficiency will not reoccur: ? Upon completion of a Uniform Assessment Instrument, the Resident Services Director will then present all forms to the Executive Director for signature of approval of appropriateness every morning in stand-up leadership meeting. ? This deficiency will be reviewed during facility monthly Quality Assurance Meetings with oversite by Governing Authority Representative.
Standard #:	22VAC40-73-560-E
Description:	Facility failed to ensure that all resident records shall be kept current. Evidence: Resident #5's nurse's notes indicate that on 7/13/19 the resident experienced gastrointestinal issues. On 7/17/19 the resident was seen by the Nurse Practitioner however this visit is not documented in the nurse's notes. There is no follow up documentation until 8/5/19 .
Plan of Correction:	a. Corrective action for Resident #5?s nurse?s notes listed in this deficiency: ? Community obtained notes from nurse practitioner?s visit on 07/17/19. b. Steps taken to identify other resident charts to ensure they do not have this deficiency: ? Nursing department to audit files ensuring that all medical visits due to an illness or incident, be followed up with a visit by the Medical Director?s team, and that the follow-up visit is documented in our nursing charts. Completed by 8/23/19 c. Measures, systems or changes put in place to ensure this deficiency will not reoccur: ? RSD has instructed our Medical Director and Team to ensure all medical visits provided for our residents be: o Documented in the nursing notes. o Following any illness or incident their next visit must have follow-up documentation in the nursing notes ? Monthly audits by nursing department to ensure that all Physician follow-ups have occurred when warranted.
Standard #:	22VAC40-73-680-M
Description:	Facility failed to ensure that medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. Evidence: Resident #5 has a PRN order for .5mg Ativan. The PRN medication was not available for administration.
Plan of Correction:	a. Corrective action for Resident #5 listed in the deficiency: ? Resident #5 medication orders and Electronic MAR has been audited to ensure all medications ordered were documented on the Electronic MAR and medication is available onsite. This was handled immediately by Resident Services Director during survey process. b. Steps taken to identify other medication concerns not identified by the survey team: ? The Resident Services Director, Executive Director, as well as the Governing Authority Representative will audit all current resident orders with the physician order set to perform a match back with the residents Electronic MAR to identify any outliers to orders. The Electronic MAR will be then be audited to the medications on hand for verification that all medications are accounted for on site. To be Completed by 8/23/19 c. Measures, Systems or changes put in place to ensure this deficiency will not reoccur: ? The Resident Services Director, along with the shift clinical nurse will perform an Electronic MAR match back to each cart once a month to verify all medications are on site. ? A Pharmacy representative will perform an onsite cart audit with Electronic MAR match back once a quarter. The Pharmacy will report findings to the Resident Services Director and the Executive Director for immediate corrections. ? This deficiency will be reviewed during facility monthly Quality Assurance Meetings with oversite by Governing Authority Representative.