VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Arden Courts (Fair Oaks)
12469 Route 50
Fairfax, VA 22033
(703) 383-0060

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Oct. 5, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic by the Governor of Virginia. A complaint inspection was initiated on 10/5/20 and concluded on 12/3/20. A complaint was received by the department regarding allegations in the area of: Resident Care and Related Services. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and a violation was issued. Any violations not related to the complaint but identified during the course of the investigation can be found 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, please contact me via e-mail at m.massenberg@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that no medication, dietary supplement, or treatment is started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Evidence: 1. Resident #1's July medication administration record (MAR) states that Resident #1's Nuplazid and multivitamin were discontinued on 7/23/20. The record for Resident #1 did not contain a discontinue order, dated 7/23/20, for Resident #1's Nuplazid or multivitamin. 2. The record for Resident #1 included a physician's order, dated 7/23/20. The 7/23/20 order discontinued Resident #1's Nystatin. The same 7/23/20 order also listed some of Resident #1's other medication, including Resident #1's Nuplazid and multivitamin, but did not discontinue these medications.
Plan of Correction:	Error occurred due to improper interpretation of an order written by hospice nurse. Hospice has agreed to write Admit Orders "continue all medications" or "discontinue" specific medications by name. RSC or designee audited all hospice charts to ensure orders are compliant and clear. RSC or designee will review all new hospice admit orders to ensue compliance.