VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Benchmark at Alexandria
3440 Berkeley Street
Alexandria, VA 22302
(571) 386-2200

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: Sept. 16, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS

Technical Assistance:

None

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/16/2024 Time In: 11:41 AM Time Out: 5:54 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 26 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: LI toured the physical plant of the facility, observed the administration of medication and observed residents involved in independent pursuits: lunch and dinner dining, residents resting in their room, lounging in the common areas, and walking around the facility. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on facility record review, the facility failed to ensure that the health information required by these standards shall be maintained at the facility and be included in the staff record for each staff person, and also shall be maintained at the facility for each household member who comes in contact with residents. Initial tuberculosis examination and report: each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. The risk assessment shall be no older than 30 days. 1. Staff 1?s (hire date, 03/04/2024) tuberculosis examination was completed on 02/14/2024. Upon request Staff 1?s risk assessment was not provided. 2. On 09/17/2024, LI received an email from Staff 4 with Staff 1?s risk assessment, 02/14/2024.
Plan of Correction:	1) Staff 1?s risk assessment was emailed to the inspector on September 17th, 2024. 2) The Director of Business Administration was In-serviced on the Tuberculin Skin Testing for Associates policy (HR-100-7) on November 6th, 2024. 3) The Director of Business Administration will audit random associate files monthly to verify that a completed TB Screening Risk Assessment is present for six months to ensure ongoing compliance.
Standard #:	22VAC40-73-640-A
Description:	Based on resident record review and staff interview, the facility failed to ensure a written plan for medication management was implemented. The facility?s medication plan shall address procedures for administering medication and shall include methods to ensure that each resident?s prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: Resident 2 (admit date, 08/28/2024), who self-administered medications had an order for Symbicort 160 mcg-4/5 mcg/actuation HFA aerosol inhaler (inhale 2 puffs twice daily) that was not available for self-administration. 2. On 09/16/2024, LI interviewed Staff 4 who confirmed that the medication was not present on-site. 3. Resident 2 has an order for Dicyclomine 20 mg tablet (instructions unavailable on medication list) that was not available for self-administration. 4. On 09/16/2024, LI interviewed Resident 2 who stated it was realized that the Dicyclomine 20 mg medication was unavailable for self-administration when preparing weekly pill organizer. Resident 2 stated that the nursing team was notified. 5. On 09/16/2024, LI interviewed Staff 4 who stated that Resident 2 informed the nursing team that Dicyclomine 20 mg had run out. Staff 4 stated that Resident 2 missed one dose, but the medication would be available the next day. Staff 4 stated that Resident 2 would only miss the one dose of medication. Staff 4 stated that the nursing team does not track the medication for those who self-administer. Staff 4 stated that there is not a timeline or a certain number of instances where the self-administer missed medication doses before re-assessing consent for self-administration. 6. Resident 2 (admit date, 03/04/2024), who self-administered had an order for Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler that was not available on-site.
Plan of Correction:	1) An up-to-date list of medications was obtained for resident number 2 on November 1st, 2024. The Dicyclomine was delivered to the community on September 16th, 2024. 2) Nurses and Medication Aides will be in-serviced on the Medication Management policy by November 30th, 2024. 3) The Resident Care Director or Designee will audit residents who self-administer medication quarterly, to ensure they have a current list of medications and that medications are available to the residents. Audits will occur for six months to ensure ongoing compliance.
Standard #:	22VAC40-73-970-E
Description:	Based on facility record review, the facility failed to ensure that the required fire and emergency evacuation drills contained number of staff and residents participating, and the time it took to complete the drill. Evidence: 1. May 2024 fire drill documentation was missing the number of staff participating. 2. June 2024 fire drill documentation was missing the time it took to complete the drill. 3. July 2024 fire drill documentation was missing the time it took to complete the drill and the number of staff participating. 4. August 2024?s fire drill documentation was missing the number of residents participating, the number of staff participating, and has two different start times, 6:45 AM and 6:52 AM.
Plan of Correction:	1) A Fire Drill will be conducted by November 30th, 2024, to include the number of staff and residents participating, and the time it took to complete the drill. 2) The Plant Operations Director was in-serviced on the Fire Safety policy (C-100-09) on November 5th, 2024. 3) The Executive Director or Designee will audit fire drills monthly to ensure the number of staff and residents participating, and the time it took to complete the drill are included on the Fire Frill/Evacuation Exercise form. Audits should occur for six months to ensure ongoing compliance.