VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sunrise of Falls Church
330 North Washington Street
Falls church, VA 22046
(703) 534-2700

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Dec. 2, 2021 and Dec. 8, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

On 12/2/2021 Licensing Inspector (LI) conducted unannounced focused monitoring visit to ensure correction of violations cited during 10/26/2021 renewal study. Medication observation was conducted, six resident records were reviewed and interviews with staff were conducted. . All previous violations were found to have been corrected. Violations of other standards were cited and reviewed with the administrator. 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 #:	22VAC40-73-650-A
Description:	Based upon a review of documents and interviews the facility failed to ensure that no medication, dietary supplement, diet, medical procedure, or treatment shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. Evidence: According to the Medication Administration Record (MAR) and observation made by Licensing Inspector, Resident #1 was administered nasal spray at approximately 9:42 am on 12/2/2021. The MAR indicates that the start date for the nasal spray was 10/05/2021. The date of admission to the facility for Resident #1 is documented in the resident's record as 10/05/2021. A physician's order for the nasal spray was not located in the record of Resident #1. Interview with Staff #2 confirmed that the facility does not have a valid physician's order for the nasal spray.
Plan of Correction:	Resident #1 experienced no negative outcomes as a result of nasal spray medication administered on 12/2/2021. A valid signed order for nasal spray for Resident #1 was received on 12/2/2021. The Resident Care Director (RCD), Wellness Nurse (WN) or designee audited resident records to confirm residents have valid signed orders for medications. The RCD conducted refresher training with the Wellness Nurses (WNs) regarding the importance of valid signed medication orders and reporting issues with orders to the RCD so that they can be addressed timely by the clinical team, pharmacy, and physician. The RCD or designee will continue to audit physician orders for 3 months to confirm orders are present in the resident's chart. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The results of the audits will be presented by the RCD or wellness designee at Quality Assurance and Performance Improvement (QAPI) meeting for 3 months. During and at the end of the 3 months the QAPI Committee will evaluate the results of the medication orders and determine if additional focus or action is warranted. The Executive Director (ED) or designated coordinator is responsible for implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
Standard #:	22VAC40-73-650-C
Description:	Based upon a review of records and interviews, the facility failed to ensure that physician's or other prescriber's oral orders shall: be reviewed and signed by a physician or other prescriber within 14 days. Evidence: According to the electronic chart for Resident #2, a verbal physician's order for Ipratropium-Albuterol Solution 0.5-2.5 (3) mg/3mL: 3ml inhale orally every six hours as needed for shortness of breath or wheezing via nebulizer was received on 11/03/2021. A signed physician's order was not found in the record of Resident #1. Interview with Staff #2 revealed that the written physician's order was still waiting for the physician to review and sign as of 12/2/2021 at approximately 1:00pm.
Plan of Correction:	A verbal physician order for Ipratropium-Albuterol Solution for Resident #2 was signed and received on 12/3/2021. The Resident Care Director (RCD), Wellness Nurse (WN) or designee audited resident records to confirm residents have verbal orders signed within 14 days of being taken. The RCD will conduct refresher training with the Wellness Nurses (WNs) regarding the process for obtaining a signature from a physician on a verbal order within the appropriate time frame. The RCD or designee will continue to audit verbal physician orders for 3 month to confirm signatures are received within the correct time frame. Issues that may be identified will be addressed and resolved and refresher training initiated as needed. The RCD or designee will present the results of the verbal order audit to the Quality Assurance and Performance Improvement Committee (AQPI) monthly for 3 months. During and at the end of the 3 months, the QAPI Committee will evaluate the results and determine if additional focus or action is warranted. The Executive Director (ED) or designee is responsible for confirming the implementation and ongoing compliance components of this Plan of Correction and addressing and resolving variances that may occur.