VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Humphrey's Retirement Home
3405 Chamberlayne Avenue
Richmond, VA 23227
(804) 329-1316

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Oct. 13, 2020

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

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 10/13/2020 and concluded on 11/02/2020. The facility Administrator was contacted by telephone to initiate the inspection. The facility Administrator reported that the current census was 22. The inspector emailed the facility Administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, physician?s orders, staffing schedules, fire drills, health care oversight, emergency preparedness practice, review of resident rights, Medication/Pharmacy review, resident?s health and physical examination reports, resident?s UAI and ISPs and resident medication administration records (MARs) submitted by the facility to ensure documentation was complete. The information gathered during the inspection and interviews conducted determined non- compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on the review of facility records and interviews with the facility Administrator the facility failed to ensure that medications were administered in accordance with the physician's or other prescriber's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: RESIDENT #1--Documented Date of Admission 08/26/2020 The Medication Administration Record (MAR) charting for August 2020 that was submitted for the inspector?s review noted that beginning 08/14/2020 twelve days before the resident?s 08/26/2020; documented date of admission, facility staff administered Cogentin-1 MG tablet to be administered by mouth 2 twice daily and Depakote 1-500 MG tablet to be administered by mouth daily; to resident #1. Upon request the facility did not submit for the inspector?s review documented evidence of the physician?s order for the medications administered to the resident.
Plan of Correction:	FACILITY RESPONSE- "Humphrey's admission policy will reflect both a quarantine admission and an actual time a client is admitted to the facility. Administrator will make sure all physician's orders and prescribers instructions are consistent with the standards and practice outlined in current medication aide curriculum."