VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise Assisted Living of McLean
8315 Turning Leaf Lane
Mclean, VA 22102
(703) 734-1600

Current Inspector: Alexandra Roberts

Inspection Date: June 24, 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 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.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A inspection was initiated on 6/24/2020 and concluded on 6/29/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 56. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records and 4 staff records. Criminal record checks and sworn statements of all staff hired since last inspection and other documentation submitted by the facility was reviewed to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-1090-A
Description:	Based on record review, 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 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 #4 was admitted to a safe, secure unit on 9/19/2019 and a Assessment of Serious Cognitive Impairment form was not in record.
Plan of Correction:	A. With respect to the specific resident/situation cited: Assessment for Resident #4 was obtained from psychiatrist which indicates that the resident has a serious cognitive impairment and is appropriate for a memory care neighborhood. The resident experienced no negative outcomes as a result of residing in the Secure Memory Care Neighborhood. The form was placed in the resident record. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Wellness Team conducted an audit of current residents? records to confirm clinical psychologist or physician completed the Initial Assessment for Serious Cognitive Impairment for neighborhood appropriateness The issue identified was resolved. C. With respect to what systemic measures have been put into place to address the stated concern: The Director of Sales will conduct the initial check followed by a second check by the Resident Care Director and/or Reminiscence Coordinator to verify resident records contain the completed Assessment for Serious Cognitive Impairment Form prior to admission into the Secure Memory Care Neighborhood. The Reminiscence Coordinator or designee will conduct monthly audits to confirm the Assessment for Serious Cognitive Impairment Form is completed and will present results of audit to the Quality Assurance and Performance improvement (QAPI) committee monthly for three months. The QAPI committee will evaluate the results of the audits during and after three months and determine if additional action is warranted or if the review period needs to be extended. D. With respect to how the plan of correction will be monitored: The Executive Director (ED) or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
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 due to a primary psychiatric diagnosis of dementia in a safe, secure environment, the facility shall obtain the written approval of one of the following persons, in the following order of priority: the resident, a guardian or other legal representative, a relative, an independent physician. Evidence: Resident #3 was admitted to a safe, secure unit on 3/10/2020 with an Approval for Placement in Special Care Unit form signed and dated 3/12/2020.
Plan of Correction:	A. With respect to the specific resident/situation cited: Written approval for placement in the Secure Memory Care Neighborhood was obtained from the Power of Attorney (POA) for Resident #3. An additional verification was completed by the ED on 7/5/2020. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director conducted an audit of current residents? initial and annual review of Approval for Placement in Special Care Unit. Issues identified were resolved. C. With respect to what systemic measures have been put into place to address the stated concern: For the next 3 months, the Reminiscence Coordinator or designee will audit resident records to confirm the records contain the written Approval for Placement in Special Care Unit from the resident, a relative, or a legal representative prior to the resident's admission into the Secure Memory Care Neighborhood. Additionally, for the next 3 months, the Reminiscence Coordinator or designee will audit the resident records to confirm compliance of semi-annual written Approval for Placement in Special Care Unit. The QAPI committee will evaluate the results of the audits during and after three months and determine if additional action is warranted or if the review period needs to be extended D. With respect to how the plan of correction will be monitored: The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-1110-A
Description:	Based on record review, facility failed to ensure that prior to admitting a resident with a serious cognitive impairment due to a primary psychiatric diagnosis of dementia to a safe, secure environment, the licensee, administrator, or designee shall determine whether placement in the special care unit is appropriate and the determination and justification for the decision shall be in writing. Evidence: Resident #3 was admitted on 3/10/2020 to a safe, secure unit and the Approval for Placement in Special Care Unit form was signed and dated by the administrator on 3/12/2020 and the explanation of written approval was not completed.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #3?s written Approval for Placement in Special Care Unit was completed by the Executive Director on 3/12/20. An additional verification was completed by the ED on 7/5/2020 B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director conducted an audit of current residents? initial and annual review of Approval for Placement in the Special Care Unit. Issues identified were resolved. C. With respect to what systemic measures have been put into place to address the stated concern: For the next 3 months, the Reminiscence Coordinator or designee will audit resident records to confirm the records contain the written Executive Director Approval for Placement prior to the resident's admission into the Secure Memory Care Neighborhood. The QAPI committee will evaluate the results of the audit during and after three months and determine if additional action is warranted or if the review period needs to be extended. D. With respect to how the plan of correction will be monitored: The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-1110-B
Description:	Based on record review, facility failed to ensure that six months after placement of the resident in the safe, secure environment, the licensee, administrator, or designee shall perform a review of the appropriateness of each resident's continued residence in the special care unit. Evidence: Resident #4 was admitted on 9/9/2019 to a safe, secure unit and a six month review was not in record; and record included an Approval for Placement form signed and dated by an administrator on 6/25/2020 and relationship and explanation of written approval areas were not completed, a Review of Appropriateness form signed and dated by an administrator on 6/11/2020 without consultation, and a Review of Appropriateness form signed and dated by an administrator on 11/11/2019 and the date of last review was not completed.
Plan of Correction:	A. With respect to the specific resident/situation cited: Resident #4?s semi-annual Approval for Placement form was signed by the Executive Director on 6/11/2020 following an audit and placed in the resident?s record. An additional verification was completed by the ED on 7/5/2020. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Executive Director conducted an audit for current residents of semi-annual reviews of Approval for Placement in the Special Care Unit. Issues identified were resolved. C. With respect to what systemic measures have been put into place to address the stated concern: For the next 3 months, the Reminiscence Coordinator or designee will audit resident records to confirm the records contain the Executive Director semi-annual Approval forPlacement in Special Care Unit. Issues that may be identified will be addressed and resolved. The QAPI committee will evaluate the results of the audit during and after three months and determine if additional action is warranted or if the review period needs to be extended. D. With respect to how the plan of correction will be monitored: The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, facility failed to ensure that he sworn statement or affirmation shall be completed for all applicants for employment. Evidence: 3/17 staff records review did not document a sworn statement (SS) completed for applicants for employment. Staff #2 was hired on 10/25/2019 with a SS dated 2/27/2020, Staff #5 was hired on 2/11/2020 with a SS dated 5/28/2020, and Staff #12 was hired 4/11/2020 with a SS dated 7/4/2020; and the three SS were completed after hired as employees and not as applicants for employment.
Plan of Correction:	A. With respect to the specific resident/situation cited: Staff # 2, #5 and #12 continue to be employed at the community and the ED reviewed the VA requirement for signing of sworn statements with each staff member. The sworn statements remain in the employee file. BOC was provided refresher training by the Executive Director on acquiring the sworn statement prior to the employment date for new employees and his/her responsibility for confirming compliance. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: BOC or designee is in the process of conducting an audit of the sworn statements for current team members Issues that may be identified will be addressed and resolved. C. With respect to what systemic measures have been put into place to address the stated concern: BOC or designee will implement a process to monitor and audit receipt of the sworn statement prior to the first day of employment for each team member, monthly for 3 months. ED or designee will review new team member checklists with the BOC during weekly 1:1 meeting beginning 7/13/2020 to confirm receipt of sworn statements. During and after the 3 months, the QAPI committee will evaluate the efficacy of the team member file audits of sworn statements and New Team Member Checklist audits to determine if continued audits are needed and/or if additional actions are necessary. D. With respect to how the plan of correction will be monitored: The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. Evidence: 2/17 staff records did not document a Criminal History Record (CHR) on or prior to the 30th day of employment. Staff #1 was hired on 7/11/2019 with a CHR dated 2/26/2020 and Staff #15 was hired on 12/20/2019 and a CHR was not in record.
Plan of Correction:	A. With respect to the specific resident/situation cited: Staff #1?s Criminal Record History (CHR) was completed with no concerns identified and placed in the file. Staff #15?s CHR was completed prior to hire date, however the documentation was not in appropriate file. Staff #15?s CHR was located and placed in employee file. B. With respect to how the facility will identify residents/situations with the potential for the identified concerns: The Business Office Coordinator (BOC) is in the process of conducting an audit of team member files to confirm required CHRs are included in the personnel files. Issues identified will be addressed and resolved. C. With respect to what systemic measures have been put into place to address the stated concern: The Business Office Coordinator (BOC) and/or Executive Director will audit newly hired team member records over the next 3 months to verify CHR compliance Issues identified will be addressed and resolved. The QAPI committee will evaluate the results of the audit during and after three months and determine if additional action is warranted or if the review period needs to be extended. D. With respect to how the plan of correction will be monitored: The Executive Director or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.