VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vinson Hall
6251 Old Dominion Dr.
Mc lean, VA 22101
(703) 536-4344

Current Inspector: Marshall Massenberg (804) 543-5188

Inspection Date: Dec. 6, 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.

Technical Assistance:

Please ensure facility staff tuberculosis forms are revised to be consistent with the Virginia Department of Health form stating that the staff is free of communicable disease.

Comments:

An unannounced renewal study was conducted from 8:50 a.m. - 6:45 p.m. on 12/06/2019. At the time of entrance 177 residents were in care. The sample size consisted of ten resident records and five staff records. Four residents and staff were interviewed. Resident, staff, volunteer and pet records and other documentation reviewed. Criminal Background Checks of all staff hired since previous inspection conducted on 3/21/2019 were reviewed. Residents were observed engaging in holiday activities. Medication administration was observed with one staff and cart observed for PRN medications. Building and Grounds observed. Violation notice issued, risk ratings reviewed and exit interview held. 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) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on observation, record review and documentation, facility failed to ensure that the facility shall implement a written plan for medication management and shall include methods to ensure that each resident's prescription medications ordered for the resident are filled in a timely manner and methods for 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 an order. Evidence: During observation of medication administration and record review, Resident #3's record documented an order dated 11/29/2019 for Lasix 20 MG every other day and MAR documented Lasix 20 MG three times per week.
Plan of Correction:	The medication management plan shall be updated by December 13, 2019 by the clinical manager in collaboration with the pharmacy providers to include methods to ensure that each resident?s prescription medications ordered for the resident are filled in a timely manner. This update to the medication management plan will include a process for verifying that the medication order has been accurately transcribed medication administration records (MARs) within 24 hours of receipt of a new order or change in an order as well as steps to take when there is a discrepancy and/or delay.