VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Jefferson
900 North Taylor Street
Arlington, VA 22203
(703) 516-9455

Current Inspector: Alexandra Roberts

Inspection Date: Jan. 20, 2021

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. 22VAC40-80 THE LICENSING PROCESS.

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 renewal inspection was initiated on 1/20/21 and concluded on 1/21/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the census was 49. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, medication administration records, local fire and health inspections, and other documentation 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. 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on record review, the facility failed to ensure that medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #2's December MAR (medication administration record) was reviewed during the inspection. Resident #2's record contained an order for Lisinopril, dated 2/17/20, that called for the resident to receive one 20mg tablet twice per day. The order stated that the medication is to be held, if Resident #2's systolic blood pressure (SBP) is less than 100 or her diastolic blood pressure (DBP) is less than 60. The MAR indicated that Resident #2 received Lisinopril on 12/31/20 (10 AM administration), when the resident's blood pressure was 111/59. Resident #3's December MAR was reviewed during the inspection. Resident #3's record contained an order for Levothyroxine, dated 9/13/20, that called for the resident to receive one 100mcg tablet every other day. The MAR indicated that Resident #3 did not receive Levothyroxine on 12/13/20, as the medication was listed as ?pending delivery.? Resident #3?s record contained an order for Carvedilol, dated 11/12/20, that called for the resident to receive one 25mg tablet twice per day with meals. The Carvedilol order stated that the medication shall be held, if the resident's SBP is below 100 or her heart rate (HR) is below 60. The MAR indicated that Resident #3 did not receive Carvedilol on 12/29/20 (9 AM administration), as the MAR states that the resident?s pulse was ?below 60/min.? The MAR listed the resident?s blood pressure as being 107/49 and her heart rate as being 71. Resident #3?s record contained an order for Ensure, dated 11/11/20, that calls for the resident to receive it two times per day. The MAR indicated that Resident #3 did not receive Ensure for several days during December, as the MAR stated that the supplement was ?pending delivery.? Resident #3 did not receive Ensure on 12/7, 12/15, 12/16, 12/17, 12/18, 12/19, 12/20, and 12/27.
Plan of Correction:	The Lisinopril order for Resident #2 and the Carvedilol order for Resident #3 were clarified to have only one parameter. Medication carts were checked to verify that the Levothyroxine and Ensure for Resident #3 were present. An automatic monthly delivery of Ensure was set up by the family of Resident #3. The Registered Medication Aides (RMAs) who documented the Lisinopril, Carvedilol, Levothyroxine and Ensure on the dates noted in the Violation Notice were given refresher training by the Resident Care Director (RCD). Residents #2 and #3 had no adverse effects related to the issues identified. Current Medication Administration Records for other residents were reviewed by the RCD to identify any other hypertensive medication orders given or held outside of parameters and to determine if any other medications or supplements were pending delivery. No other hypertensive medications were identified as given or held outside of parameters. Hypertensive medication orders with multiple parameters were clarified to have only one parameter. No other medications or supplements were identified as pending delivery and all ordered medications were available for administration. Refresher training will be provided to RMAs and LPNs responsible for medication administration by the RCD or designee regarding using parameters for hypertensive medication orders and actions to be taken when an ordered medication or supplement is not available for administration. Medication pass observations will be conducted with RMAs and LPNs responsible for medication administration by the RCD or designee to validate that they are administering medications in accordance with physician orders. If incorrect practice is observed, on-the-spot training will be provided, and additional observations will be conducted to validate correct practice. At least five random medication pass observations will be conducted with RMAs and LPNs responsible for medication administration by the RCD or designee weekly for the next month, then bi-weekly for two months, to validate that they are administering medications in accordance with physician orders. Medication carts will be checked by the RCD or designee weekly for the next month, then bi-weekly for two months to verify that ordered medications are available for administration. The results of these med pass observations and cart checks will be reviewed at Quality Assurance / Performance Improvement meetings. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-680-H
Description:	Based on record review, the facility failed to ensure that a medication administration record (MAR) is used to document all medications administered to residents, including over-the-counter medications and dietary supplements. Evidence: Resident #3?s MAR was reviewed during the inspection. The MAR did not include documentation for the administration of Resident #3?s Calazime on 12/5/20 (Night administration).
Plan of Correction:	The Registered Medication Aide (RMA) who did not document the Calazime on 12/5/20 was given refresher training by the Resident Care Director (RCD). Resident #3 had no adverse effect related to the Calazime that was not documented as administered. Current Medication Administration Records for other residents were reviewed by the Associate Executive Director (AED) to identify any other missing documentation of administration. A late entry note was written by the nurse for missing documentation that was identified. Refresher training will be provided to RMAs and LPNs responsible for medication administration by RCD or designee regarding documentation of medications administered. Medication Administration Records will be audited by the AED or designee weekly for the next month, then bi-weekly for two months, to validate that there is no missing documentation of administration. If missing documentation is identified, a late entry note will be written by the nurse. The results of these Medication Administration Record audits will be reviewed at Quality Assurance / Performance Improvement meetings. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.