Top 10 AL Deficiencies: January – June 2022
DSS has shared data on the top 10 deficiencies cited during inspections of assisted living facilities the agency conducted from Jan 2022 – March 2022 and April 2022 – June 2022.
- Citations related to individual service plans and medication administration continue to remain at the top of the list.
- Maintenance of buildings and grounds and first aid and CPR certification are in the top 10 for both quarters.
January 2022 – March 2022
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:
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22VAC40-73-450-F
Individualized service plans |
Individualized service plans shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. 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. |
22VAC40-73-870-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. |
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:
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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:
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22VAC40-73-260-A
First aid and CPR certification |
A. First aid.
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22VAC40-73-440-A
Uniform assessment instrument (UAI) |
All residents of and applicants to assisted living facilities shall be assessed face to face using the uniform assessment instrument in accordance with Assessment in Assisted Living Facilities (22VAC30-110). The UAI shall be completed prior to admission, at least annually, and whenever there is a significant change in the resident’s condition. |
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.1. Initial tuberculosis examination and report.
2. Subsequent tuberculosis evaluations and reports.
3. 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. 4. 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 |
E. 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. |
April 2022 – June 2022
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:
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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. |
22VAC40-73-640-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:
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22VAC40-73-450-F
Individualized service plans |
Individualized service plans shall be reviewed and updated at least once every 12 months and as needed as the condition of the resident changes. 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. |
22VAC40-73-260-A
First aid and CPR certification |
A. 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. |
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; and13. The signature of the examining physician or his designee. |
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. |
22VAC40-73-680-M
Administration of medications and related provisions |
M. Medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. |
22VAC40-73-870-E
Maintenance of buildings and grounds |
E. All furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard. |
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; andc. Effectiveness; and14. The name, signature, and initials of all staff administering medications. A master list may be used in lieu of this documentation on individual MARs. |