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: April 14, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 4/14/2020 Licensing Inspector (LI) conducted an inspection via desk review in response to self-reported incidents. Reviewed resident records, medication administration records, and controlled substance count forms. Violation notice issued and assessed risk assigned to violations. 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 email at jamie.eddy@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based upon a review of resident records and written statement from administrator, the facility failed to implement methods of a written plan for medication management to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. Evidence: The controlled substance community inventory count forms had mistakes that were not properly corrected with two signatures. The January 2020 Controlled Drug Receipt/Record form that would account for an accurate count of the controlled substance for Resident #1 is not available.
Plan of Correction:	Health and Wellness Associates (Medication Aides and Wellness Nurses) were re-educated on elements of the medication management plan relating to controlled substance destruction and reconciliation practices during shift changes on 2/20/2020. Education included observation of practices. Controlled substance drawer locks within each medication cart were changed on 2/24/2020. Medication cart keys on each medication cart were changed on 2/26/2020. Medication cart keys to be secured in a locked box in the Health Services Director's office. Controlled drug destruction practice changed to involve the RN Health Services Director and another nurse. Controlled substance count reconciliation observations by Health Services Director or designee to be completed weekly on various shifts for 3 months, including an audit of the inventory count sheets to ensure compliance with company policies. Auditing to be completed by the Health Services Director or designee. Corrective action will be initiated for any variances and findings will be reported to the Executive Director and Safety Committee. Person responsible for implementation: Health Services Director or designee.
Standard #:	22VAC40-73-680-M
Description:	Based upon a review of resident records and written statements from administrator, the facility failed to ensure that medications ordered for PRN administration shall be available, properly labeled for the specific resident, and properly stored at the facility. Evidence: Resident #1's PRN medication for Oxycodone (5mg Tab by mouth every six hours) was not available 2/17/2020 through 2/18/2020.
Plan of Correction:	Medication carts and refrigerators audited to ensure as-needed (PRN) medications were available, properly labeled, and properly stored for residents. Health and Wellness Associates (Medication Aides and Wellness Nurse) educated to practices related to as-needed (PRN) medications, including proper labeling, storing, ordering, and destruction of discontinued as-needed (PRN) medication. A 20% audit of as-needed (PRN) medications will be completed monthly for three months to ensure that medications ordered for as-needed (PRN) medications are available, properly labeled, and properly stored at the facility. Corrective action will be initiated for any variances and findings will be reported to the Executive Director and Safety Committee. Person responsible for implementation: Health Services Director or designee.