VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Greenspring Village
7470 Spring Village Dr
Springfield, VA 22150
(703) 923-4663

Current Inspector: Alexandra Roberts

Inspection Date: Oct. 22, 2019 and Oct. 23, 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:

Please ensure all staff and resident tuberculosis screenings are completed on forms consistent with the Virginia Department of Health documenting the absence of tuberculosis in a communicable form. (22VAC343-70-250, 22VAC43-70-320) Please ensure Assisted Living Facility Disclosure Statement is updated on the most recent form (032-05-0849-06-eng, 10/19). Please ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's records as specified in ? 63.2-1706 of the Code of Virginia, including complete staff records upon request. (22VAC40-73-40)

Comments:

An unannounced monitoring study was conducted on 10/2/2019 from 8:25 a.m. - 5:45 p.m. and 10/23/2019 from 8:15 a.m. - 3:30 p.m. with two Licensing Inspectors. At the time of entrance 149 residents were in care. The sample size consisted of ten resident records and five staff records. Six residents and staff were interviewed. Resident, staff, volunteer and pet records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection conducted on 11/30/2018 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including Trivia, Guess Who I Am and exercise in the safe, secure unit and Visiting Pets in the assisted living area. Medication administration was observed with five staff and medication carts observed for PRN medications. Building and Grounds observed; two renovated rooms measured (EV333, EV133). Violations and 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) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on record review, facility failed to ensure that prior to placing a resident with a serious cognitive impairment in a safe, secure environment, the facility shall obtain the written approval of one of the persons (resident, guardian, relative, legal representative, physician) identified in order of priority and the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate and the written decision shall be retained in the resident's file. Evidence: 1/6 records reviewed for residents residing in safe secure did not include the Approval form and the Appropriateness of Placement form in record; Resident #5's record did not include the required forms.
Plan of Correction:	a. Resident # 5 approval for placement in a special care unit was obtained and will be retained in the residents file. b. A 100% audit of current residents in the facility will be conducted to determine compliance with the approval for placement in a special care unit. Resident files found to be out of compliance will be corrected immediately with resident or their legal representative notification and receipt of approval. c. The staff development coordinator and/or designee will re-educate admissions office and managers on required admission paperwork for memory care residents to include the Virginia state form providing approval for placement in a special care unit. d. Wellness manager or designee will conduct a monthly audit x 4 months of 10% of current Memory Care residents to include all new admissions for the month to ensure compliance with presence of approval for placement in a special care unit in the resident file. Findings will be reported to the Quality Assurance and Performance Improvement Committee for review and further action as needed. e. Date of Completion: April 10, 2020
Standard #:	22VAC40-73-450-E
Description:	Based on record review facility failed to ensure that the Individualized Service Plan (ISP) shall be signed and dated by the licensee, administrator, or his designee and by the resident or his legal representative and it shall also indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution; the title or relationship to the resident of each person who was involved in the development of the plan shall be included; and these requirements shall also apply to reviews and updates of the plan. Evidence: 5/8 of the current resident records reviewed did not include the signature requirements for the ISPs. Records for Resident #3 and Resident #4 did not include a signature page for the ISP; Resident #7's record included a signature page for the ISP and not a signature of the resident or legal representative; and records for Resident #1 and Resident #8 included a signature page for the ISPs and not signatures of the residents, legal representatives or facility staff.
Plan of Correction:	a. Resident #1, #3, #4, #7 and #8 ISP?s will be reviewed and signatures with date will be obtained from the resident or their legal representative and any contributor. b. A 100% audit of assisted living/memory care ISP signature pages will be conducted to ensure compliance with signatures on ISP, reviews and updates of the plan. ISPs found to be out of compliance will be corrected to include notification to resident or their legal representative and receipt of acknowledgement. c. The administrator or designee will re-educate Assisted Living and Memory Care managers on the process of obtaining date and signature of resident or their legal representative and any contributor on the ISP, reviews and/or updates on plans. d. Administrator or designee will conduct a monthly audit x 4 months of 10% of current Assisted Living and Memory Care residents to ensure compliance with signed and dated Individualized Service Plan, in addition to any reviews and updates to the plan approval for placement in a special care unit in the resident file. Findings will be reported to the Quality Assurance and Performance Improvement Committee for review and further action as needed. e. Date of Completion: April 10, 2020
Standard #:	22VAC40-73-640-A
Description:	Based on observation and documentation, facility failed to ensure that the facility shall implement a written plan for medication management and shall include methods for the effective use of the MARs for documentation. Evidence: During observation of medication administration on 10/22/2019 at 9:20 a.m., Licensing Inspector observed Staff #1 administer medications (Aricept 5 MG, Lasix 20 MG, Claritin 10 MG, Oyster Shell Calcium 500) to Resident #1 and during Staff #1's documentation of the administration of the medications on the MAR it was observed that Staff #3 had previously documented the administration of the same medications; interviews with management and medication aids during the investigation determined that Staff #3 had documented the administration of the medications and had not given the medications before the responsibility of medication administration was given to Staff #1.
Plan of Correction:	a. Staff #1 and Staff #3 were reeducated on proper medication management to include documentation on the MARs regarding medication administration. b. A medication pass will be observed with Staff #1 and Staff #3 to ensure competency in the process. c. The staff development coordinator and/or designee will re-educate assisted living and memory care medication aide staff on proper medication management processes to include documentation. d. Wellness manager or designee will conduct medication pass observation of 10% of Memory Care and Assisted Living residents a week x 4 weeks, then monthly x 4 months to ensure staff are compliant with medication management and documentation. Findings will be reported to the Quality Assurance and Performance Improvement Committee for review and further action as needed. e. Date of Completion: April 10, 2020