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: Sept. 19, 2019

Complaint Related: No

Areas Reviewed:

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

Comments:

Licensing Inspector (LI) conducted an unannounced monitoring inspection on 9/19/19 in response to the facility's probationary status. At the time of entrance 81 residents were in care. Four resident records were reviewed. Each resident whose record was reviewed had been involved in an incident self-reported by the facility to the regional licensing office. Resident records and monthly task logs were reviewed as were medication administration records. Four individual interviews were conducted. A walk though of the physical plant was completed. Possible violations were discussed at the exit interview. 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(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 me at (703) 479-5247 or contact me via email at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based upon a review of records and interview with staff, the facility failed to ensure that the facility shall report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: On three occasions the facility failed to report within 24 hours to the regional licensing office incidents that negatively affected the life, health, safety, or welfare of residents.
Plan of Correction:	Three facility reported incidents were submitted to the licensing inspector on 9/19/2019. Directors and Health & Wellness associates to be educated on reporting practices related to resident incidents that negatively affect or threaten the life, health, safety, or welfare of a resident. A 50% audit of resident incidents completed monthly to ensure timely submission of reportable incidents to the regional licensing office. 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.
Standard #:	22VAC40-73-680-D
Description:	Based upon a review of medication administration records, the facility failed to ensure that medications shall be administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: Resident #1 has a physician's order for Acetaminophen 325 mg two tablets by mouth every eight hours as needed for pain. On September 8, 2019, the resident was given a dose at 10:28 am and again at 4:16 pm. Eight hours had not passed before the second dose was administered at 4:16 pm.
Plan of Correction:	Medication Aide who administered the PRN acetaminophen educated on proper practices related to PRN medication administration. An audit of residents' Medication Administration Records (MARS) will be completed to ensure PRN medications are administered according to the physician's orders. Medication Aides to be educated on practices related to PRN medication. A 20% audit of PRN medication orders to take place monthly for 3 months, to ensure PRN medications are administered according to the physician's orders. Corrective action will be initiated for any variances and findings will be reported to the Executive Director. Person responsible for implementation: Health Services Director or designee.