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Virginia Health Care Association | Virginia Center for Assisted Living

Top AL Deficiencies for Q4 2023

The Voice of VCAL March 20, 2024

Top AL Deficiencies for Q4 2023

DSS has shared data on the top deficiencies cited during inspections of assisted living facilities the agency conducted from October – December 2023.

  • The top five citations continue to be related to individual individualized service plans, medication administration, and physical examination and report.

 

Of note, medication management moved from the fifth most cited to second most citied item.

  • During our annual Assisted Living Symposium on April 11, we will have a session dedicated to best practices in medication management.

 

In Q3 2023, citations for failing to meet Virginia Code requirements to obtain criminal history records on or prior to the thirtieth day of employment for each employee first appeared on the top citations list.

  • This has persisted as a top violation in Q4.

 

Moving on the list: Admission and retention of residents with any of the prohibiting conditions is new to the list of top citations this quarter.

Dropping off the list: Since the last quarter, fewer facilities have been cited for the activity and recreational requirements related to the required criteria included in the written schedule of activities.

October 2023 – December 2023: Top Deficiencies Summary

Ranking Regulatory Standard
1 22VAC40-73-(6)-450-C
2 22VAC40-73-(6)-640-A
3 22VAC40-73-(6)-450-F
4 22VAC40-73-(6)-680-D
5 22VAC40-73-(3)-260-A
5 22VAC40-73-(5)-320-A
6 22VAC40-73-(2)-70-A
6 22VAC40-73-(6)-680-I
7 22VAC40-73-(3)-250-D
8 22VAC40-73-(6)-450-E
8 22VAC40-90-(BC3)-40-B
9 22VAC40-73-(5)-310-H
9 22VAC40-73-(8)-870-A

  

October 2023 – December 2023: Regulatory Standard Detail

22VAC40-73-450-C Individualized service plans The comprehensive individualized service plan shall be completed within 30 days after admission and shall include the following:

  1. Description of identified needs and date identified based upon the (i) UAI; (ii) admission physical examination; (iii) interview with resident; (iv) fall risk rating, if appropriate; (v) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (vi) other sources;
  2. A written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them;
  3. When and where the services will be provided;
  4. The expected outcome and time frame for expected outcome;
  5. Date outcome achieved; and
  6. For a facility licensed for residential living care only, if a resident lives in a building housing 19 or fewer residents, a statement that specifies whether the resident does or does not need to have a staff member awake and on duty at night.
22VAC40-73-640-A Medication management plan and reference materials The facility shall have, keep current, and implement a written plan for medication management. The facility’s medication plan shall address procedures for administering medication and shall include:

  1. Methods to ensure an understanding of the responsibilities associated with medication management;
  2. Standard operating procedures, including the facility’s standard dosing schedule and any general restrictions specific to the facility;
  3. Methods to prevent the use of outdated, damaged, or contaminated medications;
  4. 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;
  5. Methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order;
  6. Methods for monitoring medication administration and the effective use of the MARs for documentation;
  7. Methods to ensure that MARs are maintained as part of the resident’s record;
  8. Methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes;
  9. Methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22VAC40-73-670;
  10. Methods to ensure that staff who are responsible for administering medications are adequately supervised, including periodic direct observation of medication administration;
  11. A plan for proper disposal of medication;
  12. Methods to ensure that residents do not receive medications or dietary supplements to which they have known allergies;
  13. Identification of the medication aide or the person licensed to administer drugs responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber;
  14. Methods to ensure that staff who are responsible for administering medications are trained on the facility’s medication management plan; and
  15. Procedures for internal monitoring of the facility’s conformance to the medication management plan.
22VAC40-73-450-F Individualized service plans Individualized service plans shall be reviewed and updated at least once every 12 months and as needed for a significant change of a resident’s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident’s family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons.
22VAC40-73-680-D

 

 Administration of medications and related provisions Medications shall be administered in accordance with the physician’s or other prescriber’s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing.
22VAC40-73-260-A First aid and CPR certification First aid.

  1. Each direct care staff member shall maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. The certification must either be in adult first aid or include adult first aid. To be considered current, first aid certification from community colleges, hospitals, volunteer rescue squads, or fire departments shall have been issued within the past three years.
  2. Each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.
  3. A direct care staff member who is a registered nurse, licensed practical nurse, or currently certified emergency medical technician, first responder, or paramedic does not have to meet the requirements of subdivisions 1 and 2 of this subsection.
  4. In each building, there shall either be (i) at least one staff person at all times who has current certification in first aid that meets the specifications of this section; or (ii) an on-duty registered nurse, licensed practical nurse, or currently certified emergency medical technician, first responder, or paramedic.
22VAC40-73-320-A Physical examination and report Within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following:

  1. The person’s name, address, and telephone number;
  2. The date of the physical examination;
  3. Height, weight, and blood pressure;
  4. Significant medical history;
  5. General physical condition, including a systems review as is medically indicated;
  6. Any diagnosis or significant problems;
  7. Any known allergies and description of the person’s reactions;
  8. Any recommendations for care including medication, diet, and therapy;
  9. 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;
  10. A statement that the individual does not have any of the conditions or care needs prohibited by 22 VAC 40-73-310 H;
  11. A statement that specifies whether the individual is considered to be ambulatory or nonambulatory as defined in this chapter;
  12. A statement that specifies whether the individual is or is not capable of self-administering medication; and
  13. The signature of the examining physician or his designee.
22VAC40-73-70-A Incident reports Each facility shall 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.
22VAC40-73-680-I Administration of medications and related provisions The MAR shall include:

  1. Name of the resident;
  2.  Date prescribed;
  3. Drug product name;
  4. Strength of the drug;
  5. Dosage;
  6. Diagnosis, condition, or specific indications for administering the drug or supplement;
  7. Route (e.g., by mouth);
  8. How often medication is to be taken;
  9. Date and time given and initials of direct care staff administering the medication;
  10. Dates the medication is discontinued or changed;
  11. Any medication errors or omissions;
  12. Description of significant adverse effects suffered by the resident;
  13. For “as needed” (PRN) medications:a. Symptoms for which medication was given;
    b. Exact dosage given; and
    c. Effectiveness; and
  14. The name, signature, and initials of all staff administering medications. A master list may be used in lieu of this documentation on individual MARs.
    a. Symptoms for which medication was given;
    b. Exact dosage given; and
    c. Effectiveness.
22VAC40-73-250-D Staff records and health requirements 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.
  •  Subsequent tuberculosis evaluations and reports.
    • Any staff person or household member required to be evaluated who comes in contact with a known case of infectious tuberculosis shall be screened as determined appropriate based on consultation with the local health department.
    • Any staff person or household member required to be evaluated who develops chronic respiratory symptoms of three weeks duration shall be evaluated immediately for the presence of infectious tuberculosis.
    • Each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free 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.
  • Any individual suspected to have infectious tuberculosis shall not be allowed to return to work or have any contact with the residents and personnel of the facility until a physician has determined that the individual is free of infectious tuberculosis.
  • The facility shall report any active case of tuberculosis developed by a staff person or household member required to be evaluated to the local health department.
22VAC40-73-450-E Individualized service plans The individualized service plan shall be signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. The plan shall also indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person who was involved in the development of the plan shall be included. These requirements shall also apply to reviews and updates of the plan.
22VAC40-90-40-B

 

 General Requirements The criminal history record report shall be obtained on or prior to the 30th day of employment for each employee.
22VAC40-73-310-H Admission and retention of residents H. In accordance with § 63.2-1805 D of the Code of Virginia, assisted living facilities shall not admit or retain individuals with any of the following conditions or care needs:

  1. Ventilator dependency;
  2. Dermal ulcers III and IV except those stage III ulcers that are determined by an independent physician to be healing;
  3. Intravenous therapy or injections directly into the vein, except for intermittent intravenous therapy managed by a health care professional licensed in Virginia or as permitted in subsection K of this section;
  4. Airborne infectious disease in a communicable state that requires isolation of the individual or requires special precautions by the caretaker to prevent transmission of the disease, including diseases such as tuberculosis and excluding infections such as the common cold;
  5. Psychotropic medications without appropriate diagnosis and treatment plans;
  6. Nasogastric tubes;
  7. Gastric tubes except when the individual is capable of independently feeding himself and caring for the tube or as permitted in subsection K of this section;
  8. Individuals presenting an imminent physical threat or danger to self or others;
  9. Individuals requiring continuous licensed nursing care;
  10. Individuals whose physician certifies that placement is no longer appropriate;
  11. Unless the individual’s independent physician determines otherwise, individuals who require maximum physical assistance as documented by the UAI and meet Medicaid nursing facility level of care criteria as defined in the State Plan for Medical Assistance Program (12VAC30-10); or
  12. Individuals whose physical or mental health care needs cannot be met in the specific assisted living facility as determined by the facility.
22VAC40-73-870-A Maintenance of buildings and grounds The interior and exterior of all buildings shall be maintained in good repair and kept clean and free of rubbish.
Posted in Assisted Living, DSS
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