VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Great Falls
10200 Colvin Run Road
Great falls, VA 22066
(703) 759-2513

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: July 25, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced monitoring inspection was conducted 7/25/19 in response to the facility's probationary status. At the time of entrance 82 residents were in care. The sample size consisted of five resident records. Resident records and monthly task logs were reviewed. LI walked the physical plant and there was verification that the alarms to the doors on the secured care unit were operational. Staffing schedules were reviewed as were medication administration records. Possible violations were discussed at the exit meeting. 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 #:	22VAC40-73-680-I
Description:	Based on a review of Medication Administration Records (MARS) the facility failed to ensure that The MAR shall include: diagnosis, condition, or specific indications for administering the drug or supplement. Evidence: For Residents #1, #2, #3, and #4 the diagnosis, condition, or specific indications for administering the drug or supplement were missing for prescribed medications.
Plan of Correction:	1) Steps to correct the non-compliance: Medication orders for residents #1, #2, #3, #4 were reviewed and corrected on July 25, 2019 to include diagnoses and/or specific indications for administering the drug. 2) Measures to prevent the non-compliance: An audit of medication orders for residents will be completed to ensure orders include diagnosis, condition, or specific indications for administering the drug or supplement. Wellness Nurses, medical director, and nurse practitioner to be educated on ensuring new orders included diagnosis, condition, or specific indications for administering the drug or supplement. 3) Person responsible for implementing and/or monitoring: A 20% audit of medication orders to take place monthly for 3 months, to review orders for comprehensiveness. Corrective action will be initiated for any variances and findings will be reported to the Health Services Director. Person responsible for implementation: Health Services Director or designee (11/5/2019).
Standard #:	22VAC40-73-680-K
Description:	Based upon a review of resident's records, the facility failed to ensure that that the use of PRN medications is prohibited, unless one or more of the following conditions exist: Medication aides administer the PRN medication when the facility has obtained from the resident's physician or other prescriber a detailed medication order. The order shall include directions as to what to do if symptoms persist. Evidence: The physician's or other prescriber's orders for "as needed" (PRN) medications did not include what to do if symptoms persist for the following residents: Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5.
Plan of Correction:	1) Steps to correct the non-compliance: PRN orders for residents #1, #2, #3, #4, #5 reviewed and corrected on August 6, 2019 to include directions on what to do if symptoms persist. 2) Measures to prevent the non-compliance: An audit of PRN medication orders for residents will be completed to ensure orders include what to do if symptoms persist. Wellness Nurses, medical director, and nurse practitioner to be educated on practices related to PRN medication orders, including ensuring that PRN orders include directions as to what to do if symptoms persist. Medication Aides to be educated on practices related to PRN medications administration, including steps to take after PRN medications are administered. 3) Person responsible for implementing and/or monitoring: A 20% audit of PRN medication orders to take place monthly for 3 months, to review PRN orders for comprehensiveness. Corrective action will be initiated for any variances and findings will be reported to the Health Services Director. Person responsible for implementation: Health Services Director or designee (11/5/2019).