VIRGINIA DEPARTMENT OF SOCIAL SERVICES

West Falls Center at Falcons Landing
46661 Algonkian Parkway
Potomac falls, VA 20165
(703) 404-5300

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Sept. 10, 2019 and Sept. 11, 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 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. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Licensing Inspector (LI) reviewed the standard for developing an individualized service plan seven days prior or the day of admission and that the comprehensive service plan must be developed within 30 days of admission. LI reviewed the standard regarding fire drills for each shift in a quarter shall not be conducted in the same month.

Comments:

An unannounced renewal study was conducted on 9/10/19 and 9/11/19. At the time of entrance 40 residents were in care. The sample size consisted of eight resident records, two discharge records, four staff records, one volunteer record and four individual interviews. Resident and staff records and other documentation were reviewed. Criminal Background Checks of all staff hired since the previous inspection conducted on 9/20/2018 were reviewed. Residents were observed eating breakfast and lunch and engaging in activities including chapel services, arts and craft, and morning mind bender. Medication administration was observed. 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 #:	22VAC40-73-250-D
Description:	Based upon a review of staff records, the facility failed to ensure that each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: There were 16 staff records that did not contain current documentation that the individuals were free from tuberculosis in a communicable form.
Plan of Correction:	The 12 missing staff records of PPD screenings during the time of inspection were located and corrected on 9/11/19. The 3 missing staff records of PPD screenings will be completed on 9/20/19 when staff returns for scheduled work shifts. The 1 missing staff record of PPD screening will be completed on 9/30/19 when staff returns from planned time off. Monthly audits of staff PPD screenings will be conducted for the next quarter. Monthly reminders from the Wellness Center and Human Resource Department will be reviewed by the Nursing Coordinator and Administrator upon receipt and forwarded to the corresponding supervisor for completion.
Standard #:	22VAC40-73-320-A
Description:	Based upon a review of resident records, the facility failed to ensure that within the 30 days preceding admission, a person shall have a physical examination by an independent physician. The report of such examination shall be on file at the assisted living facility and shall contain the following: the person's address and telephone number; the person's height, weight, and blood pressure. Evidence: The history and physical report for Resident #2 did not contain the resident's address, phone number, height, and weight. For Resident #3 the history report for Resident #3 did not contain the resident's address or weight. The history and physical report for Resident #5 did not contain the resident's weight. For Resident #6 the history and physical report did not contain the resident's height or weight. The history and physical report for Resident #7 did not contain the resident's weight.
Plan of Correction:	All five resident's (Resident #2, #3, #5, #6, and #7) History and Physical records were corrected to include address, phone number, height, and weight on 9/19/19. Discussed with admitting physician importance of completing the information. Admitting nurse will ensure all resident address, phone number, height, and weight are noted in the HP. Monthly audits will be conducted by the Nursing Coordinator and reported to the Director of Nursing. Findings will be included in the quarterly assurance report for further recommendations.
Standard #:	22VAC40-73-650-B
Description:	Based upon a review of resident records, the facility failed to ensure that 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: The physician orders for Residents #1, #2, #3, and #4 failed to identify the diagnosis, condition, or specific indications for administering each drug for all of the prescribed medications.
Plan of Correction:	All four resident's (Resident #1, #2, #3, and #4) medication records during the time of inspection were noted of diagnosis and/or condition for administering prescribed medications on 9/12/19. Physician orders audit of all current residents will be completed on 9/30/19. Physicians orders will be audited monthly by the Nursing Coordinator and reported to the Director of Nursing to ensure all prescribed medications indicate a diagnosis and/or reason for administering prescribed medications. Completed audits will be included in the quarterly assurance report for further recommendations. All nurses and medication technicians will complete re-training by 9/30/19 in ensuring notation of diagnosis and/or condition for administering prescribed medications.