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: June 18, 2020 and Aug. 6, 2020

Complaint Related: Yes

Areas Reviewed:

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

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 complaint inspection was initiated on June 18, 2020 and concluded on August 8, 2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 91. The inspector emailed a list of items required to complete the inspection. The inspector reviewed resident records, staff records and other items submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. The complaint was determined valid A corrective action is to be submitted by August 13, 2020

Violations:

Standard #:	22VAC40-73-40-B-12
Complaint related:	Yes
Description:	Based on resident and facility record review and staff interviews, it was determined the licensee failed to ensure that at all times the department's representative is afforded reasonable opportunity to inspect all of the facility's buildings, books, and records and to interview agents, employees, residents, and any person under its custody, control, direction, or supervision as specified in ? 63.2-1706 of the Code of Virginia. Evidence: 1. The LI conducted a teleconference with the Administrator, Director of Leadership Development, and Chief Compliance Officer on July 7, 2020. At that time, the LI reviewed the request for the fall policy that specified care and documentation provided to a specific resident after a fall. Staff A and B stated the LI had the current fall policy and procedure, in its entirety, and staff were following that policy. The aforementioned policy sent was dated 2016. This LI recovered a previous policy request that was sent as part of an investigation that was dated 2018. This 2018 policy was not received as requested by the LI. A third fall policy dated 2019 and titled Fall Management Program ? Alabama was received on July 21, 2020. . 2. The LI then sent the following request for information on July 7, 2020: ?Thank you for providing the residents? names for the fall report. Please provide the responsible party name, and responsible party's telephone number, fall risk assessment, all documentation for each resident the month of June 2020, UAI, admission physical and current ISP for the following residents. The first three residents have had multiple falls. Please provide the fall risk assessment for each fall. Resident M, O, N, and L. *Staff schedule for all direct care and administrative staff for June 2020. *Room numbers for the residents that require two person assist to exit in the event of a fire. *Room numbers of residents that require the assistance of one person to exit in the event of a fire. Do not include the resident on the second floor. ? The following requested information was not provided to the LI: The MARs/TARs medication/treatment administration records for Residents L, M, N and O Resident L care notes from 6/1/20 through 6/10/20 Staff schedule for direct care staff on the secured unit. Staff schedule for the administrator. 3. The LI requested the following information via email June 24, 2020: ?Please send me the resident name, responsible party name, and responsible party's telephone number, fall risk assessment, all documentation associated with the injury (aide notes, nurse notes, etc.) and current ISP for any residents that have fallen, or had injury of an unknown origin, in the past 15 days. This would be all falls, whether the resident received outside medical care or not.? Resident C?s documentation was sent to the LI. The LI confirmed with the administrator that this was the only fall, or injury, in the past two weeks. A collateral contact stated that other residents had fallen during that time period. A verification email was sent to the administrator on July 6, 2020, requesting updated information. The administrator then sent a list of 10 falls that had occurred since June 15, 2020 and July 3, 2020.
Plan of Correction:	Facility provided requested information on 6/15/20, 6/22/20, 6/24/20, 6/26/20, 6/29/20, 7/2/20, 7/6/20, 7/7/20, 7/8/20, 7/21/20. Facility will no longer utilize Policies & Procedures in a hard copy format at the community, but instead utilize the electronic version on a shared folder to ensure the most current version is referenced; effective 8/17/2020.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on resident and facility record review and staff interviews as part of a complaint inspection, it was determined the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: The administrator provided a listing of all falls or incidents that required a resident being sent to the hospital since 12/19/2020. December 19, 2019 was the last reported incident for a fall from the facility. Four incidents, involving three residents were listed that were not reported to the regional licensing office within 24 hours as required. On July 3, 2020, the facility notified the population that a staff person had tested positive with COVID 19. The Division of Licensing Programs was notified of this positive test on July 7th, at the LI request.
Plan of Correction:	All incidents that are required to be reported per regulations will be reported to department within 24 hours of incident occurring. President and Vice President providing in-service to 100% nursing team and Memory Care Experience Coordinator by 8/31/20 on this expectation. Monthly Quality Assurance reviews with experience team will review for compliance beginning 8/2020, then converting to quarterly in Q1 of 2021.
Standard #:	22VAC40-73-150-C
Complaint related:	Yes
Description:	Based on collateral interviews, it was determined the administrator was not responsible for the general administration and management of the facility including overseeing the day-to-day operation of the facility. Evidence: Two complainants alleged the administrator would not return calls. A collateral contact supported the allegation. The administrator confirmed the allegation in a teleconference on July 15, 2020; stating other team members would contact the family members or residents, or the family members and residents knew who else they could contact.
Plan of Correction:	President providing in-service of 100% leadership team by 8/31/20 on the expectation of copying President on follow-up communication with residents/responsible parties and encouraging the team to remind residents/responsible parties they are responding on behalf of the President. All complaints/concerns will be kept in community Grievance Binder that will be maintained by the community First Impressions Concierge and Community President. All Grievances will be discussed at QA meetings.
Standard #:	22VAC40-73-220-A
Complaint related:	No
Description:	Based on resident record review and staff interview, it was determined the facility failed to ensure all oversight regulations were met when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility. Evidence: Criminal record checks received on July 15, 2020 determined all staff come from the same home health agency. Resident M has documentation in the record of having private duty personnel. The facility confirmed the personnel were providing nightly care. The facility failed to provide the following information: documentation of type and frequency of services, documentation on the ISP of services provided by private duty personnel, documentation of orientation and training of facility policies, documentation of the monitoring of services to residents with private duty personnel.
Plan of Correction:	Facility provided requested information on 7/21/20. Facility will continue to maintain required documentation regarding Private Duty Personnel on the ISP and in the resident?s admin record. Resident with Private Duty Personnel will have ISP?s updated by 8/31/20 to reflect current plan of care for all residents. All ISP care plans will be updated with any significant change of condition, or quarterly for MC residents, every 6 months for AL residents. Monthly Quality Assurance reviews with experience team will review for compliance beginning 8/2020, then converting to quarterly in Q1 of 2021.
Standard #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on staff record review and staff interviews, it was determined the facility failed to maintain a written work schedule that includes the names and job classifications of all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: The administrator schedule received on June 18, 2020, did not list the time worked each day. The schedule documented the number of hours worked on a scheduled day. For example, June 11th 24 hours The administrator sent a schedule on July 8, 2020 for the leadership team for June, 2020. The schedule listed everyone had worked from 9 to 5. The administrator stated in an interview on July 15, 2020, leadership worked their own schedule, she did not know or verify the exact hours that were worked.
Plan of Correction:	President will post the monthly leadership team schedule, including the Leader on Duty coverage for the weekend in the shared work room by 8/21/20. All staff work schedules will be maintained by community department leaders and posted the at least 2 weeks in advance. Monthly Quality Assurance reviews with experience team will review for compliance beginning 8/2020, then converting to quarterly in Q1 of 2021.
Standard #:	22VAC40-73-310-A
Complaint related:	Yes
Description:	Based on resident record review and staff interviews it was determined the facility admitted and retained a resident who required a level of care or service or type of service for which the facility is not licensed. Evidence: Resident M ISP 1/15/2020, has documentation on the current ISP of requiring a two person assist. The facility provided a listing of 5 other residents that require a two person assist. The terms of the facility license prohibit more than 5 residents that require this level of care. Resident M began physical therapy 7/13/2020
Plan of Correction:	Vice President, with the input of third-party service providers to reassess functionality and appropriateness of residents to determine level of assistance needed; completed by 9/15/20. Monthly Quality Assurance reviews with experience team will review for compliance beginning 8/2020, then converting to quarterly in Q1 of 2021.
Standard #:	22VAC40-73-450-C
Complaint related:	Yes
Description:	Based on resident record review and staff interviews, it was determined that the facility failed to document on the ISP the required information within the 30 days of admission. Evidence: The ISPs received for Residents M and N, contain two separate ISPs. The standard requires one master ISP. Resident O and L?s ISP does not identify description of need, is not dated, not noted who and where provided, and date of expected outcome. Resident M ISP did not address the use of private duty personnel.
Plan of Correction:	President and Vice President providing in-service to 100% nursing team and Memory Care Experience Coordinator by 9/15/20 on the Care Plan and ISP creation and updates to accurately reflect resident care. Monthly Quality Assurance reviews with experience team will review for compliance beginning 8/2020, then converting to quarterly in Q1 of 2021.
Standard #:	22VAC40-73-480-C
Complaint related:	Yes
Description:	Based on resident record review and staff interviews it was determined the facility failed to arrange for specialized rehabilitative services by qualified personnel as needed by the resident. Evidence: Resident O had PT and OT ordered on admission physical of June 25, 2020. No documentation was presented that PT or OT have been contacted.
Plan of Correction:	President and Vice President providing in-service to 100% nursing team and Memory Care Experience Coordinator by 9/30/20 on documentation and follow-up regarding new orders for residents. Experience Team to review new admission charts for completion within 48 hours of admission. Monthly Quality Assurance reviews with experience team will review for compliance beginning 8/2020, then converting to quarterly in Q1 of 2021.