VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arleigh Burke Pavilion
1739 Kirby Road
Mc lean, VA 22101
(703) 506-6900

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on resident record review and staff interview, it was determined that the facility failed to have a comprehensive Individualized Service Plan (ISP) for residents in care. Evidence: Resident A, B and C did not have documentation of a comprehensive ISP to address hospice care, bedside rails and Home Health therapies.
Plan of Correction:	The Director of Nursing and/or designee will ensure that all identified needs of residents on the UAI have a corresponding written description of what services will be provided to address identified needs. Director of Nursing and/or designee will ensure each ISP is reviewed and updated annually or if there is a change in the resident's condition to include the assessed needs as per the UAI. Community will continue to complete the preliminary ISP and comprehensive ISP in conjunction with the resident and family while using the History and Physical, physician orders, UAI, and other support to ensure the individualized basic needs of the resident are adequately identified to include the type of assistance needed. The Administrator and /or designee will complete random monthly audits of a minimum of 5 comprehensive ISPs to ensure ongoing compliance.