VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise at Hunter Mill
2863 Hunter Mill Road
Oakton, VA 22124
(703) 255-1006

Current Inspector: Alexandra Roberts

Inspection Date: Nov. 13, 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 11/13/2020 and concluded on 11/19/2020. The associate executive director was contacted by telephone to initiate the inspection. The associate executive director reported that the current census was 72. The inspector emailed the administrator and the executive associate director 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 licensed to practice in the Commonwealth 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. The physician shall be board certified or board eligible in a specialty or subspecialty relevant to the diagnosis and treatment of serious cognitive impairments (e.g., family practice, geriatrics, internal medicine, neurology, neurosurgery, or psychiatry). The assessment shall be in writing and shall include the following areas: Cognitive functions, Thought and perception, Mood/affect, Behavior/psychomotor, Speech/language, and Appearance. Evidence: Resident #1 was admitted to a safe, secure environment on 8/19/2019 with a "Physical examination" signed and dated on 8/16/2019 by a Nurse Practitioner (NP); and an "Assessment of Serious Cognitive Impairment" signed and dated on 8/22/2019 by a NP, not prior to the placement in the environment and not by a psychologist or physician.
Plan of Correction:	The Resident Care Director (RCD) contacted the Primary Care Physician overseeing the Nurse Practitioner who completed the original assessment on 8/22/19, to review and attest that resident #1 has a serious cognitive impairment due to a primary to psychiatric diagnosis of dementia with an inability to recognize danger or protect his own safety and welfare. The Resident Care Director (RCD) or designee to conduct an audit of the Assessment of Serious Cognitive Impairment (ASCI) forms for residents that reside in the Safe, Secure Environment/Special Care Unit (Reminiscence neighborhood) to verify the residents were assessed by an independent clinical psychologist, or an independent physician. Any Resident with an ASCI that was not completed by an independent clinical psychologist, or an independent physician will be scheduled to obtain an updated ASCI. The RCD or designee conducted re-education with the wellness team on admission requirements to a Reminiscence neighborhood. Prior to a resident moving in the community?s Reminiscence neighborhood, the RCD reviews the required move in documents, including the ASCI. The ASCI will be reviewed to verify that the assessment was conducted by an independent clinical psychologist, or an independent physician. For the next 3 months prior to a resident moving in the community?s Reminiscence neighborhood, the Executive Director (ED/Administrator) or designee reviews the required move in documents, including the ASCI. The ASCI will be reviewed to verify that the assessment was conducted by an independent clinical psychologist, or an independent physician. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices. The ED or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
Standard #:	22VAC40-73-1110-A
Description:	Evidence: Resident #2 was admitted to a safe, secure environment on 8/27/2020 with an Approval for Placement in Special Care Unit signed and dated by the facility representative on 8/27/2020 and an explanation of why written approval was not obtained from each individual higher on the list of priority was not provided.
Plan of Correction:	ED completed a new Approval for Placement in Special Care Unit (APSCU) form and documented explanations for order of priority as required. The resident remains appropriate for residency in the Special Care Unit. The RCD or designee conducted an audit of the Approval for Placement in Special Care Unit (APSCU) form for residents that reside in the Reminiscence Neighborhood to verify the ED or designee has determined whether placement in the Reminiscence neighborhood is appropriate prior to the resident moving in and the form includes an explanation of why written approval was not obtained from each individual higher on the list of priority. The ED will be informed of any Resident without an APSCU to schedule completion of the APSCU. The RCD or designee conducted re-education with the wellness team on admission requirements to a Reminiscence neighborhood. Prior to a resident moving in the community?s Reminiscence Neighborhood, the RCD reviews the required move in documents, including the APSCU. The APSCU will be reviewed to verify that the ED or designee has determined whether placement in the Reminiscence neighborhood is appropriate prior to the resident moving in and the form includes an explanation of why written approval was not obtained from each individual higher on the list of priority. For the next 3 months prior to a resident moving in the community?s Reminiscence Neighborhood, the ED or designee reviews the required move in documents, including the APSCU to verify timely completion by the ED or a designee and to verify the form includes an explanation of why written approval was not obtained from each individual higher on the list of priority. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices. The ED or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.
Standard #:	22VAC40-90-30-B
Description:	Based on record review, facility failed to ensure that the sworn statement or affirmation shall be completed for all applicants for employment. Evidence: 1/12 staff records reviewed did not include a sworn statement for an applicant. Staff #8 was hired on 9/15/2020 with a sworn statement dated 11/13/2020 as an employee and not as an applicant.
Plan of Correction:	Staff # 8 is no longer employed at the community. The BOC or designee conducted an audit of the Sworn Statements for new staff (team member) from the previous 3 months. Issues that maybe identified will be addressed and resolved. The Sworn Statement of Affirmation will be provided to all new applicants prior to hire, for completion. BOC will verify that the Sworn Statement of Affirmation is completed prior to moving forward in the hiring process of new team members. The ED will verify the completion of the Sworn Statement of Affirmation prior to approving new team members for hire. During the Quality Assurance and Performance Improvement (QAPI) meeting and up to 3 months following the implementation of the Plan of Correction (POC), the ED will review the POC and the results of the audit with the Department Heads. Additional improvement plans will be developed and implemented as necessary, including training to correct any deficient practices. The ED or designee is responsible for implementation and ongoing compliance with the components of this Plan of Correction and for addressing and resolving variances that may occur.