VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Avalon House on Cawdor Court
8103 Cawdor Court
Mclean, VA 22102
(301) 656-8823

Current Inspector: Alexandra Roberts

Inspection Date: May 2, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 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

Technical Assistance:

Medication review not clear. Suggested more streamline and easy to read medication review form.

Comments:

Type of Inspection: Monitoring Inspection Date of Inspection: May 2 2024 -9am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 0 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 1 Observations by licensing inspector: The LI observed medication administration, residents eating lunch and participating in other scheduled activities. LI spoke with 1 family member present during the inspection. An exit meeting will be conducted to review the inspection findings. 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. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alexandra Roberts, Licensing Inspector at 804-845-6956 or by email at Alexandra.n.roberts@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-310-M
Description:	Based on record review and staff interview, the facility failed to have a written agreements between the assisted living facility and any hospice program that provides care in the facility. Evidence: 1. Resident 2?s record contained an order for hospice services on 03/05/2024 to begin with Goodwin Home Hospice. 2. The facility did not have a written agreement between the facility and the hospice organization. 3. Staff 1 confirmed that they do not have any contracts or agreements with any hospice providers.
Plan of Correction:	Management team has reached out to all hospice programs they work with requesting an agreement between hospice & the Avalon Facilities be put in place. Once these have been executed, facility/management team will ensure the home has a copy to be kept at the facility
Standard #:	22VAC40-73-450-D
Description:	Based on record review, the facility failed to detail the specific services provided by each party on the individualized service plan (ISP). Evidence: 1. Resident 2 was admitted to hospice on 03/05/2024 with Goodwin House Hospice. 2. Resident 2?s ISP dated 2/08/2024 with an update on 3/8/2024 did not contain specific services that would be provided by each party. 3. Staff 1 confirmed they were not aware the details needed to be on the ISP.
Plan of Correction:	While it was documented Resident B was on hospice on their ISP & facility would work with the hospice team, it was not documented that hospice prescribed the pain medications & would be overseeing the pain management for that resident. That information has been added to their ISP. Administrator will be including that information on ISPs going forward.