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: Oct. 22, 2020 and Oct. 27, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 complaint inspection was initiated on 10/22/2020 and concluded on 10/27/2020. A complaint was received by the department regarding allegations in the areas of resident care. The administrator was contacted by email to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation did not support the allegation of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice. 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
Complaint related:	No
Description:	Based upon a review of records, the facility failed to implement a written plan for medication management to verify 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. Evidence: The October 2020 Medication Administration Record (MAR) has the 10/14/2020 physicians' order for Benefiber Oral Powder written as follows: Benefiber Oral Powder 1 Tablespoon PO Morning Instructions: mixed with or sprinkled onto soft food (NOT in a drink) for loose stool; twice a week." The telephone/verbal orders log sheet of 10/14/2020 for the facility has the physicians' order for Benefiber Oral Powder written as follows: "Benefiber daily 1 tsp daily for loose stool."
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 transcribing medication and how to conduct 24hour chart checks to note any discrepancies with physician orders and transcribed orders. To be completed by 11/13/2020. Audits of physician orders and MARS will be conducted and completed by 11/23/2020. 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 quality assurance committee for further recommendation.