VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Johnson Center at Falcons Landing
20535 Earhart Place
Potomac falls, VA 20165
(703) 404-5201

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Sept. 1, 2020 and Sept. 2, 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 32.1 Reported by persons other than physicians 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.

Technical Assistance:

A completed Renewal Application must be submitted prior to the expiration of the current license. The facility should receive an application in the mail, however if an application has not been received one can be obtained from the DSS web site or by calling the main office at 703-934-1505.

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 9/1/2020 and concluded on 9/2/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 14. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records, health and fire inspection reports, fire drill reports, healthcare oversight report, dietary oversight reports, and staff schedule submitted by the facility to ensure documentation was completed. Criminal Background Checks of all staff hired since the previous inspection conducted on 10/9/2019 were reviewed. Information gathered during the inspection determined non-compliance(s) with applicable standards or laws, and violations were documented on the violation notice issued to the facility. Areas of non-compliance are identified on the violation notice. 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 standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call 703-479-5247 or contact me via e-mail at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based upon a review of resident records, the facility failed to implement a written plan for medication management 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: A physician's order for Travatan Z Ophthalmic Solution 0.004% 1 drop each eye at bedtime was written on 5/13/2020 for Resident #1. On 8/17/2020 and 8/18/2020 Resident #1 did not receive the scheduled medication as the facility was waiting on delivery from pharmacy and medication was not available for administration.
Plan of Correction:	Item identified for Resident #1 did not adversely affect resident. In-service training was given to staff involved to prevent future occurrence. Ongoing in-service training will be given to staff on the expectations for medication re-ordering and will be instructed to re-order medications not in the re-order cycle when the medication has seven days worth left. Audits of medication quantity for current residents will be conducted and completed by 9/23/2020. Monthly audits will be completed by the nursing coordinator and findings reported to the Director of Nursing. The Director of Nursing or designee will report any findings or trends to the QA committee for further recommendation.
Standard #:	22VAC40-73-650-B
Description:	Based upon a review of resident records, the facility failed to ensure that physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall identify the diagnosis, condition, or specific indications for administering each drug. Evidence: For Resident #1, the physician's order for Imdur Oral Tablet 60mg 1T in morning and Restasis Ophthalmic Emulsion eye drops in the morning and evening did not identify the diagnosis, condition, or specific indications for administering each drug. For Resident #2, the physician's order for Toprol XL 25mg 1T in morning did not identify the diagnosis, condition, or specific indications for administering the drug.
Plan of Correction:	Items identified for Resident #1 and Resident #2 were corrected on 9/4/2020. No residents were adversely affected. The facility will identify other residents having the potential to be affected by the same practice by doing the following: Staff involved will be in-serviced to prevent future occurrence. Ongoing in-service for staff to ensure that all prescriptions identify the diagnosis, condition, or specific indications for administering each drug. Audits of all physician orders for current residents will be conducted and completed by 9/23/2020. Monthly audits will be completed by the Nursing Coordinator and findings reported to the Director of Nursing and staff will be identified for reeducation. The Director of Nursing or designee will report any findings to the QA committee for further recommendation.