VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Raspberry Hill Adult Daytime Center
1381 Crossings Centre Dr., Suite A
Forest, VA 24551
(434) 525-4422

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: July 14, 2021 and July 15, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION, AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS. 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2(19.2) Criminal Procedures. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

A renewal inspection was initiated on 7/13/2021 and concluded on 7/15/2021. The director was contacted by telephone to initiate the inspection. The director reported that the current census was four. The inspector emailed the director a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed two resident records, two staff records, activities calendar, staff schedules, fire/health inspections, emergency evacuation drills, and other documents submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 7/15/2021. An exit interview was conducted with director on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-61-50-E
Description:	Based on participant record review, the facility failed to have an annual review of participant rights and responsibilities with a participant. EVIDENCE: 1. The most recent review of participant rights and responsibilities for participant 2 was on 2/18/2021. This was noted on 7/14/2021.
Plan of Correction:	This has been corrected. The facility will begin using electronic reminders.
Standard #:	22VAC40-61-220-A
Description:	Based on participant record review, the facility failed to complete a written assessment of a participant prior to or on the date of admission. EVIDENCE: 1. Resident 1 was admitted on 5/24/2021 and the written assessment was done on 5/26/2021.
Plan of Correction:	From now on, assessments will be done prior to admission.
Standard #:	22VAC40-61-240-A
Description:	Based on participant record review, the facility failed to have a signed written agreement at or prior to the time of admission for a participant. EVIDENCE: 1. Participant 1 was admitted on 5/24/2021 and the agreement was signed on 5/28/2021.
Plan of Correction:	From now on, agreements will be signed prior to the first date of attendance.
Standard #:	22VAC40-61-300-A
Description:	Based on observation and participant record review, the center failed to implement their medication management plan. 300-A-4 requires that supplies or each participant's prescription and over the counter drugs and supplements be maintained in a timely manner to avoid missed dosages. 300-A-5 requires that medication orders have been accurately transcribed to the MARs. EVIDENCE: 1. The medication administration record (MAR) for resident 1 shows this resident is to have Lasix 40 mg every other day as needed for fluid retention. The order was dated 5/24/2021. Observation shows the medication was not in the facility. An interview with staff 1 reveals this resident was attending twice a week. 2. The MAR for resident 3 shows this resident is to have nitroglycerin 0.4 mg to be given daily. The medication in the cart showed it expired and was to be discarded by 10/3/2020. This was noted on 7/15/2021. Per interview with staff 1, participant 3 was attending one day a week. 3. The medication order dated 4/1/2021 for resident 3 shows that nitroglycerin 0.4mg is to be given at home only, and the July 2021 MAR shows this medication is to be given daily in the facility.
Plan of Correction:	From now on, the director will audit the orders, MARs, and medications on hand immediately, with weekly expiration date checks, and thereafter a complete audit every six months. The director will use an electronic reminder system so this is not overlooked. The director obtained an updated order for resident 1 on 7/16/2021, and the medication is no longer required to be in the facility. The director corrected the inaccurate MAR for resident 3.