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: Aug. 17, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

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 monitoring inspection was initiated on 8/17/2020 and concluded on 8/17/2020. Self-reported incidents were received by the department in regards to resident care. The administrator and care coordinators were contacted by email to conduct the investigation. The licensing inspector emailed the care coordinators a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. 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 e-mail at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-460-D
Description:	Based upon a review of resident records and witness statements, the facility failed to provide supervision of resident schedules, care, and activities, including attention to specialized needs, such as wandering from the premises. Evidence: Resident #1 was able to exit the memory care unit at approximately 8:15 am on 8/7/2020. Resident #1 was found in a different building on the campus and returned to the memory care unit at approximately 8:55 am on 8/7/2020.
Plan of Correction:	Staff Development Coordinator or designee will ensure that 100% of assisted living staff receive elopement education. Education completed by 8/27/2020. Staff Development Coordinator or designee will complete ongoing elopement education for 3 months, including resident elopement drills. Completion by 11/27/2020. Neighborhood Manager will reassess 100% of assisted living residents to determine risk of elopement and update individualized service plans appropriately. Completion by 1127/2020.
Standard #:	22VAC40-73-930-D
Description:	Based upon a review of resident records, the facility failed to ensure that for each resident with an inability to use the signaling device, in addition to any other services, the following shall be met: the individualized service plan shall specify a minimal frequency of daily rounds to be made by direct care staff to monitor for emergencies or other unanticipated resident needs. Evidence: The Individualized Service Plan (ISP) dated 8/4/2020 identifies that Resident #1 is unable to use a signaling device to call for assistance due to impaired cognition but does not specify the minimal number of daily rounds to be made made by direct care staff to monitor for emergencies or other unanticipated resident needs.The ISP states that Resident #1 "will be rounded on routinely throughout the day, including every two hours at night to ensure my safety and care needs are met."
Plan of Correction:	Neighborhood Manager or Clinical Wellness Manager will update 100% of individualized service plans to specify the minimal frequency of daily rounds to be made by direct care staff for those residents unable to use a signaling device. Completion by 9/27/2020. Neighborhood Manager or designee will complete monthly audit of 10 residents per neighborhood to ensure compliance of frequency of daily rounds for 3 months beginning 8/27/2020. Finds of the audit will be reviewed and monitored through QAPI process and adjusted as necessary.