VIRGINIA DEPARTMENT OF SOCIAL SERVICES

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

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: April 23, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 4/23/2020 Licensing Inspector (LI) conducted unannounced inspection via desk review in response to self-reported incidents. Reviewed resident records and written statements provided by facility administration. Violation notice issued and assessed risk ratings to violations. 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 email at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-H
Description:	Based upon a review of resident records, statements of staff and statements made by administrative staff, the facility failed to ensure that the care and services specified in the individualized service plan are provided to each resident. Evidence: A staff member acknowledged to administrative staff that she "tried additional times to administer medication" to Resident #1 who had declined medication when it was initially offered. The current Individualized Service Plan (ISP) for Resident #1 specifies "at times I refuse my medications; staff should give me time and try again later." Administrative staff also indicated that "this practice (trying additional times to administer medications after a refusal) is not consistent with the staff member's training which is to walk away and attempt to administer the medication at a later time."
Plan of Correction:	Staff member received education on 4/18/2020 on resident abuse and neglect, and best practices when working with cognitively impaired residents; this was prior to her return to work. Staff Development Coordinator or designee will observe staff member administer medications of five residents for three months beginning 5/10/2020 to ensure that administration practices are in accordance with training and consistent with the resident's individualized service plan. Staff Development Coordinator or designee will ensure that 100% of the Registered Medication Aides are educated on the Medication Administration Policy and Procedure by 5/23/2020.