VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tribute at The Glen
4151 Old Bridge Road
Woodbridge, VA 22192
(571) 402-1870

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Dec. 30, 2019 and Jan. 7, 2020

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

Comments:

Date of Inspection: December 30, 2019 and January 7, 2020; 9am to 3:00pm Type of Inspection: Renewal Census 106 10 resident charts reviewed, 7 staff charts reviewed and 9 interviews If you have any questions or email changes, please do not hesitate to contact me at ken.koontz@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. All previous self-reported incidents were reviewed at this time

Violations:

Standard #:	22VAC40-73-1140-C
Description:	Based on interviews and chart review and as part of a renewal inspection, it was determined the facility failed to ensure all staff received the required dementia training. Evidence: Three of three staff persons reviewed that had worked more than 4 months did not have documentation of attending at least 10 hours of training in cognitive impairment developed and provided by a licensed health care professional practicing within the scope of his profession who has at least 12 hours of training in the care of individuals with cognitive impairments due to dementia
Plan of Correction:	1. All new team members regardless of position receive 2 hours of training in cognitive impairment through on-line training. 2. All direct care team members on the memory care floor are required to have 10 hours of training in cognitive impairment within 4 months. Administrator is required to have 12 hours of training in cognitive impairment with 3 months. 3. All direct care team members and administrator will receive additional training from the National Institute for Dementia Education (NIDE) training. The NIDE training will be conducted by our in-house certified NIDE trainer. 4. All required dementia training will be completed by February 2020.
Standard #:	22VAC40-73-710-C
Description:	Based on observations, interviews and chart review and as part of a renewal inspection, it was determined the facility failed to maintain the required oversight when a restraint was used. Evidence: Residents A, B and C beds were observed with bedrails. Residents A and C reside on the secured unit. Staff stated the rails were used to assist with mobility, but the residents were unable to explain why the rails were in place. Resident B did understand the assistance of the bedrails, but the use was not delineated on the ISP. The facility did not provide the required oversight of a restraint, including but not limited to: ? Be imposed in accordance with a physician's written order that specifies the condition, circumstances, and duration under which the restraint is to be used ? Restraints shall only be applied by direct care staff who have received training in their use as specified by subdivision 2 of 22 VAC 40-73-270; ? The facility shall closely monitor the condition of a resident with a restraint, which includes checking on the resident at least every 30 minutes; ? The facility shall assist the resident with a restraint as often as necessary, but no less than 10 minutes every hour, for his hydration, safety, comfort, range of motion, exercise, elimination, and other needs; ? Direct care staff shall keep a record of restraint usage, outcomes, checks, and any assistance required in subdivision 4 of this subsection and shall note any unusual occurrences or problems. ? Restraints shall be used in accordance with the resident's service plan, which documents the need for the restraint and includes a schedule or plan of rehabilitation training enabling the progressive removal or the progressive use of less restrictive restraints when appropriate; ? Before the initial administration of a restraint, the facility shall explain the use of the restraint and potential negative outcomes to the resident or his legal representative and the resident's right to refuse the restraint and shall obtain the written consent of the resident or his legal representative;
Plan of Correction:	1. Immediately survey the use of Halo safety rings in all AL and MC suites. 2. For AL suites, residents will be allowed to keep Halo safety rings if they can explain why the Halo is in place. In these cases, the Halo safety ring is not considered a restraint. 3. For MC suites, resident are not allowed the use of Halo safety rings. Any Halo safety ring found will be removed immediately. 4. Any authorized use of halo safety ring as an assistive device will be delineated in the resident?s ISP. 5. Hold in-service training for MC care team on the non-use of bedrails and halo safety rings in memory care. This includes reporting to memory care coordinator if a family member has installed bedrails/halo safety ring on a resident bed without requesting permission. 6. Resident A uses a day bed for sleeping (head board/foot board/side board). Due to the bed design having three (3) sides, the day bad is not authorized. Resident A family will replace the day bed with a normal bed. 7. Resident C halo safety ring has been removed. 8. Resident B uses a halo safety ring and understand the use/purpose of the assistive device. Resident B use of the halo safety device will be delineated in the resident ISP. 9. This item will by completed by February 2020.