VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Goodwin House Alexandria
4800 Fillmore Ave
Alexandria, VA 22311
(703) 824-1000

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: April 23, 2019 and April 24, 2019

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 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. 22VAC40-80 SANCTIONS.

Technical Assistance:

A completed Renewal Application must be submitted prior to the expiration of the current license, if not already done. An application may be obtained from the DSS website dss.virginia.gov or by calling the main office at 703-934-1505. Please provide a copy of the facility's current passed, full-system fire inspection report to your inspector to process the renewal application.

Comments:

An unannounced renewal study was conducted from 8:30a.m. - 5:00p.m. on 4/23/19 and 9:30am - 4:30pm on 4/24/19. At the time of entrance 55 residents were in care. The sample size consisted of eight resident records including two discharged resident records, and four staff records. Three residents, one family member, staff and ancillary staff were interviewed. Resident, staff, volunteer and pet records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection conducted on 5/30/2018 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including Chair Exercise, Daily Chronicles, Reminiscing Group, This or That, Bingo, Move n Groove, and Happy Hour. Medication administration was observed with three staff and medication carts observed for PRN medications. Building and Grounds observed. Violation notice issued, risk ratings reviewed and exit interview held. 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 703-895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	The facility shall have, keep current, and implement a written plan for medication management that shall address procedures for administering medication and shall include methods to ensure an understanding of the responsibilities associated with medication management and standard operating procedures, including the facility's standard dosing schedule; methods to prevent the use of outdated medications; and methods to ensure that residents do not receive medications or dietary supplements to which they have known allergies. Evidence: During medication administration on 4/23/2019 at 10:45am, LI observed Staff #2 administer medications scheduled for 9:00am to Resident #3 including Furosemide 20mg, Digoxin 125MG, Probiotic 10 billion, and Vitamin D3 1,000 unit; and Resident #3 record included an order on 4/16/2019 for Tylenol 325MG for 2 tablets as needed (PRN) and Tylenol 500MG tablets were observed on the medication cart for Resident #3 with an expiration date of 05/2014. Resident #3's physical examination dated 3/12/2019 notes allergies to Eliquis (recurrent bleeding), Elavil (dizziness) and Pradaxa (nausea/anorexia); and Eliquis is not noted on the list of allergies on the profile page of the electronic medical administration record and Eliquis is not noted on the list of allergies on the Individualized Service Plan (ISP) dated 3/21/2019.
Plan of Correction:	The Goodwin House Alexandria medication management plan will be updated to include detailed procedures for administering medication and methods to ensure understanding of those procedures. Medication observation will be performed by the Charge Nurse quarterly for 2 cycles and then semi-annually. Registered Medication Aides will be re-educated to ensure an understanding of those procedures. Medication observation will be documented and maintained in the Administrator?s office. This will specifically address the standard dosing schedule, methods to prevent the use of outdated medications, and methods to ensure residents do not receive dietary supplements or medications to which they have known allergies. The Charge Nurse will audit the medication carts and/or medication cabinets for any outdated medications. The Assisted Living Administrator will review face sheets and Individualized Service Plans on MatrixCare to reflect correct allergies. Responsible Person: Assisted Living Administrator
Standard #:	22VAC40-73-660-A-3
Description:	Based on observation, facility failed to ensure that the individual responsible for medication administration shall keep the keys to the storage area on his person. Evidence: During observation of medication administration on 4/23/2019 to Resident #1 and Resident #2, Licensing Inspector observed Staff #1 walk away from the medicine cabinets located in each residents' private rooms with the keys hanging on a lanyard from the locks on the cabinets doors while assisting the residents in their respective rooms.
Plan of Correction:	The Assisted Living Administrator will discuss with RMAs and LPNs the importance of keeping keys to storage on the responsible person when administering medication. Random audits will be performed by the Assisted Living Administrator throughout the year. Medication observation will be performed by Charge Nurse quarterly for 2 cycles and then semi-annually for Registered Medication Aides. Responsible Person: Assisted Living Administrator
Standard #:	22VAC40-73-680-M
Description:	Medications ordered for PRN administration shall be available. Evidence: Resident #3's as needed (PRN) medications ordered on 4/16/2019 for Robitussin DM 5mg-1--mg/5mL and for Dulcolax 10mg were not available during observation of medication administration on 4/23/2019 with Staff #2.
Plan of Correction:	The Assisted Living Charge Nurse will be responsible for making sure PRN medications are available in the medication cart. The Charge Nurse will do an audit of the medication cart on a quarterly basis. The Assisted Living Administrator will discuss the importance of having PRN medications available at all times with all Assisted Living nursing staff. Responsible Person: Assisted Living Administrator and Charge Nurse