VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Avalon House on Gelston Circle
1011 Gelston Circle
Mc lean, VA 22102
(301) 656-8823

Current Inspector: Alexandra Roberts

Inspection Date: June 3, 2019 , June 18, 2019 and July 31, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Unannounced inspections were conducted on 6/3/19, 6/18/19, and 7/31/19, in response to complaints that were received by the licensing office on 5/16/19 and 7/16/19. Resident records and facility documents were reviewed. The allegations were determined to be valid, as a preponderance of evidence supported the allegations. The violations were discussed and an exit meeting was 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 standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-170-B
Complaint related:	Yes
Description:	Based on documentation, the facility failed to ensure that the administrator serves on a full-time basis, proportioning his time to all of the facilities served. Evidence: The facility?s administrator schedule (April, May) was observed during the inspection. Staff #1 served as the administrator for two facilities, during the reviewed time period. Staff #1 was not scheduled to work at the facility, from 3/31/19 ? 4/13/19. Staff #1 was scheduled to work for five hours, from 4/14/19 ? 4/20/19. Staff #1 was scheduled to work for four hours, from 4/21/19 ? 4/27/19. Staff #1 was scheduled to work for two hours, from 4/28/19 ? 5/4/19. Staff #1 was not scheduled to work at the facility, from 5/5/19 - 5/11/19. Staff #1 was scheduled to work for five hours, from 5/12/19 ? 5/18/19. Staff #1 was scheduled to work for two hours, from 5/19/19 ? 5/25/19. Staff #1 was scheduled to work for four hours, from 5/26/19 ? 6/1/19. Staff #1's schedule, at the other facility, listed him as working from eight to 12 hours per week.
Plan of Correction:	Management will ensure administrator of record schedule document which reflects at least 10 hrs. per week is accurate. Amendments, schedule, changes, or substitution of administrator of record will be typed or handwritten on posted schedule as they occur.
Standard #:	22VAC40-73-560-E
Complaint related:	Yes
Description:	Based on observation and interview, the facility failed to ensure that all resident records are retained at the facility. Evidence: The licensing inspector requested Resident #1?s record, after arriving at the facility on 6/3/19. Facility staff reported that the record was not present. Another staff member brought the record back to the facility, shortly after the inspector?s arrival.
Plan of Correction:	Responsible party mentioned to staff they were requesting a copy of the chart. A copy machine is not kept on site. Chart was taken to office to copy. Should this occur in the future, it will be documented at the home where the chart is and when it will be returned to facility. Chart was brought over during inspection.
Standard #:	22VAC40-73-650-C
Complaint related:	No
Description:	Based on record review, the facility failed to ensure that physician?s oral orders are charted by the individual that takes the order. Evidence: Facility staff reported that the notes on Resident #1?s Physician order form, dated 4/29/19, were oral orders from the physician. The individual that took the order, was not documented on the physician order form.
Plan of Correction:	RN will retrain Med Tech about proper procedures documenting oral orders from physician.
Standard #:	22VAC40-73-650-E
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that the resident record contains the physician?s signed written order or a dated notation of the physician's or other prescriber's oral order. Evidence: Resident #1?s orders, signed by the physician on 5/2/19, for Docusate, Boost, Vitamin D and Vitamin C were not in the resident record, during the inspection on 6/3/19.
Plan of Correction:	Responsible party requested from staff a copy of the chart. A copy machine is not on site. It was taken to office to be copied. Orders were accidentally left in copy machine when the chart was being returned for the inspector. Orders were emailed to inspector immediately after inspection and returned to chart. If a chart is being taken to office to make a copy, it will be documented in the home along with when it will be returned.