VIRGINIA DEPARTMENT OF SOCIAL SERVICES

West Falls Center at Falcons Landing
46661 Algonkian Parkway
Potomac falls, VA 20165
(703) 404-5300

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Oct. 13, 2020 and Nov. 3, 2020

Complaint Related: No

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 monitoring inspection was initiated on 10/13/2020 and concluded on 11/3/2020. A self-reported incident was received by the department regarding allegations in the area 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 self-report of non-compliance with standards or law. Any violations not related to the self-report but identified during the course of the investigation can be found 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 #:	22VAC40-73-680-A
Description:	Based upon a review of records and interview with administration, the facility failed to ensure that staff who are licensed, registered, or acting as medication aides on a provisional basis as specified in 22VAC40-73-670 shall administer drugs to those residents who are dependent on medication administration as documented on the UAI. Evidence: Resident #1 has a physician's order for Magic Cup 1 serving PO Special: daily Times of Administration 3:00 pm Instructions: Supplement. Resident #1 has a private duty aide who is not an employee of the facility. Progress notes entered on 10/13/2020 at approximately 2:11 pm states "Resident's private aide give magic cup to this resident most of the times." A second progress note entered on 10/13/2020 at approximately 2:18 pm states "Resident's private aide give magic cup to this resident most of the times (10/2,03,04,07,12/2020)." The October 2020 Medication Administration Records (MARS) reports that on October 2nd, 3rd, 4th, 7th, 8th, and 12th of 2020 the administration of the Magic Cup was skipped. The reason given for the skipped medication was reported on the MARS as "resident may self administer medications or clinical findings refer to record documentation." The Uniform Assessment Instrument dated 3/2/2020 and the Individualized Service Plan dated 3/2/2020 state that Resident #1 needs assistance with medication management.
Plan of Correction:	The involved staff was in-serviced on medication management and administration on 10/13/2020. A medication pass observation with the involved staff was conducted by the facility's partner pharmacy, PharMerica, on 11/10/2020. All nurses, medication technicians, and CNA's will be in-serviced on medication management and administration by 11/20/2020. All nurses, medication technicians, and CNA's will be in-serviced on UAI and ISP review by 11/20/2020. A clinical audit of all residents taking supplements will be completed by 11/16/2020 and monthly thereafter. This audit will be included and reported in the quarterly QA.