VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Great Falls Assisted Living
1121 Reston Avenue
Herndon, VA 20170
(703) 421-0690

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: March 30, 2023

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 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. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Documentation was discussed with the provider.

Comments:

An unannounced renewal inspection was conducted on 3/30/23 (8:10 AM - 5:20 PM). At the time of entrance, 56 residents were in care. Meals, medication administration, and activities were observed. Building and grounds were inspected. Records were reviewed. The sample size consisted of eight resident records and four staff records. Violations were discussed and an exit meeting was held. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (I) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Marshall Massenberg, Licensing Inspector at (703) 431-4247 or by email at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on documentation, the facility failed to implement the medication management plan: verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in order. Evidence: Resident #1 was prescribed PRN Tums and PRN Acetaminophen on 2/1/23. Resident #1's PRN medications (ordered on 2/1/23) were not included on his MAR, at the time of the medication cart inspection.
Plan of Correction:	The Director of Health and Wellness will ensure an audit is conducted of all current physician order sheets as compared to the medication administration records (MARs) to ensure all current physician orders are present on the MARs. Any discrepancies identified will be corrected. The Director of Health and Wellness will ensure re-education is conducted with Coordinators of Health and Wellness regarding the process of transcribing physicians? verbal orders. All physician orders will be faxed to the pharmacy, stamped ?faxed? on physician order with date and initial, and the physician order will be flagged for 24-hour chart check to be conducted by the Assistant Director of Health and Wellness or designee. The Coordinator of Health and Wellness will ensure that the medication is delivered and placed into the correct medication cart. The Director of Health and Wellness will conduct a random audit of 10% of the residents? medical records to compare the physician orders to the MARs for three months or until substantial compliance is achieved. The Director of Health and Wellness, Assistant Director of Health and Wellness and Coordinators of Health and Wellness.
Standard #:	22VAC40-73-650-C
Description:	Based on record review, the facility failed to ensure that physician's oral orders are reviewed and signed by the physician within 14 days. Evidence: Resident #7's record was reviewed during the inspection. The record contained Bacitracin orders (12/1/22 and 12/7/22) that were not signed by the physician, within 14 days of the order date.
Plan of Correction:	The Director of Health and Wellness will ensure an audit of all physician orders is conducted to verify all orders have been signed by the physician. Any discrepancies noted will be corrected. The Director of Health and Wellness will ensure re-education is conducted with Coordinators of Health and Wellness regarding the requirement for all telephone orders to be reviewed and signed by the physician within 14 days. Each physician has a folder for documents to be signed. The telephone order will be carried out as ordered, placed in folder, signed by Physician within 14 days, and then filed in the resident medical record. An audit of all medical records will be conducted monthly for three months or until substantial compliance is achieved to ensure all physician orders are timely signed.