VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Brightview Woodburn
3450 Gallows Road
Annandale, VA 22003
(703) 462-9998

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Oct. 1, 2019 and Oct. 2, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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.

Comments:

An unannounced renewal study was conducted on 10/1/2019 and 10/2/2019. At the time of entrance 93 residents were in care. The sample size consisted of 10 resident records, five staff records, two volunteer records and three individual interviews. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous monitoring inspection conducted on 9/5/18 were reviewed. Residents were observed eating breakfast and engaging in activities including bingo and chair exercises. Medication administration was observed and the physical plant was walked. 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 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 #:	22VAC40-73-220-A
Description:	Based upon a review of resident records and observation, the facility failed to ensure that when private duty personnel from licensed home care organizations provide direct care or companion services to residents in an assisted living facility, the following applies: that direct care or companion services provided by private duty personnel to meet identified needs shall be reflected on the resident's individualized service plan. Evidence: Resident #1 has a private duty caregiver who was observed assisting resident with feeding. The services provided by the private duty caregiver were not reflected on the resident's individualized service plan.
Plan of Correction:	A 100% audit of all residents receiving private duty personnel or companion aide services will be conducted. The Health Services Director (HSD) or designee will ensure the ISP's for individuals receiving such services accurately reflects the assistance that the private duty personnel or companion aides are providing. The Executive Director (ED) will conduct quarterly audits of 100% of the ISP's for residents receiving these services to ensure compliance.
Standard #:	22VAC40-73-650-B
Description:	Based upon a review of resident records, the facility failed to ensure that the physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall identify the diagnosis, condition, or specific indications for administering each drug. Evidence: For Resident #7, the physician's orders for Gabapentin did not include the diagnosis, condition, or specific indications for administering the drug.
Plan of Correction:	The HSD or Wellness Nurse (WN) will not accept any orders without diagnoses and will obtain clarification for diagnoses before submitting such orders to the pharmacy. The community will also contract with the pharmacy consultant to audit 20% of orders every 60 days to ensure that all orders have an appropriate diagnosis. A weekly audit of all orders in QuickMAR will be performed by the HSD or designee to ensure no orders are missing diagnoses.