VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Lady Of Peace
751 Hillsdale Drive
Charlottesville, VA 22901
(434) 973-1155

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Oct. 18, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

The assigned inspector was on site on 10/18/2019 to conduct the facility?s renewal inspection. The facility Administrator was not on site upon the arrival of the inspector but arrived shortly thereafter. A brief entrance interview to explain the purpose of the inspection was conducted with a facility front office staff member. The noncompliance observed during the morning medication administration pass is contained within this report and was discussed with the facility Administrator upon her arrival. Based on the resident census offered of 134, the inspector reviewed 10 (ten) residents and 5 (five) staff records for compliance. The inspector also reviewed other facility documents for compliance. The facility is encouraged to closely monitor the implementation of their medication administration program to ensure appropriate and adequate delivery of services. Resident and staff interviews were conducted. A walk through of the physical plant revealed no obvious concerns. On 10/21/2019 the inspector conducted a telephone interview with facility staff for clarification of faciilty documentation. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov. if further assistance is needed.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on the review of facility records and interviews conducted with the facility?s Administrator on 10/18/2019, the facility failed to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Evidence: ? The EMAR Dashboard Report titled ?Held? from 10/1/19 ? 10/18/19 obtained by the licensing representative during the 10/18/2019 inspection, showed approximately 22 residents did not have medication on-site for administration for at least one dose as noted on the report by documentation of ?Other: unavailable?, ?Other, not available? or ?Other: awaiting Rx: delivery.? ? The facility policy titled, ?Administration of Medications? revised December 13, 2018 states, ?Medication fills and refills shall be timely to avoid missed dosages. Medications should be reordered according to the pharmacy procedures or electronic record vendor procedures. If a medication that is ordered does not arrive as scheduled, the Director of Nursing or designee shall be notified so that the pharmacy can be contacted via telephone for a stat delivery or follow electronic record policy for checking status.? No documentation was at the facility indicating that any of these procedures were completed.
Plan of Correction:	FACILITY RESPONSE-"The EMAR Dashboard ?Held? report will be run by the Charge Nurse during each shift to determine if there are any medications, supplements or treatments due to be administered that are not available. If this occurs, the Charge Nurse will request a stat pharmacy delivery, or the medication will be taken out of the RxNow unit to avoid any missed dosages. The Charge Nurse will call the ADON or DON if they need assistance to resolve any issues on the ?Held? report. All resident medication, treatment and supplement orders will be reviewed, and on-site availability will be confirmed on a weekly basis with an order to cart audit by the UM. If it is determined that an adequate supply is not available, the UM will be responsible for contacting the pharmacy to obtain the medication, treatment or supplement to avoid missed dosages. The Quality Assurance Nurse will review the ?Administration of Medications? policy with all medication aides and licensed nurses every six months. The Pharmacy Manual will also be reviewed in relation to the procedure for ordering medications."
Standard #:	22VAC40-73-680-C
Description:	Based on a review of facility records and interviews with facility staff, the facility failed to ensure that medications were administered no later than one hour after the facility?s dosing schedule, except those drugs that are ordered for specific times. Evidence: The EMAR Dashboard Reports titled, ?Early, Missed, and Late? all printed on October 18, 2019 and obtained by the licensing representative while at the facility on the same date showed medications/treatments prescribed by a physician and/or other prescriber with a Status of ?Late? on the report. First Floor: Approximately 6 residents totaling approximately 15 doses/treatments Second Floor: Approximately 3 residents totaling approximately 14 doses/treatments
Plan of Correction:	FACILITY RESPONSE- "The EMAR Dashboard ?Early, Late, Missed? report will be monitored throughout each shift by the Charge Nurse on duty. If a medication aide or a licensed nurse is behind, the Charge Nurse will be responsible for helping ensure medications are administered in a timely manner. All medication aides and licensed nurses were educated by the ADON on the procedure for documenting the specific reason a medication was documented as ?late? by 11/15/2019. This information will be reviewed by the ADON or UM on a weekly basis to determine if changes need to be made for specific residents, or if the staff assignments need to be revised to complete the medication pass in a timely manner. The Quality Assurance Nurse will review the ?Administration of Medications? policy with all medication aides and licensed nurses every six months. The Pharmacy Manual will also be reviewed in relation to the procedure for ordering medications. The Quality Assurance Nurse will complete a medication pass audit on all medication aides and licensed nurses once every six months, or more often if deemed necessary based on the results of the audit."
Standard #:	22VAC40-73-680-D
Description:	Based on a review of facility records and interviews with facility staff, 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: The EMAR Dashboard Reports titled, ?Early, Missed, and Late? all printed on October 18, 2019 and obtained by the licensing representative while at the facility on the same date showed medications/treatments prescribed by a physician and/or other prescriber with a Status of ?Missed? on the report. A licensing representative asked staff #XX what ?missed? meant and the staff member stated, ?It means that the resident did not receive the medication.? First Floor: Approximately 21 residents missed a minimum of 190 doses/treatments. Second Floor: Approximately 9 residents missed a minimum of 46 doses/treatments Second Floor: Approximately 6 residents missed a minimum of 112 doses/treatments
Plan of Correction:	FACILITY RESPONSE- "The EMAR Dashboard ?Early, Late, Missed? report will be monitored throughout each shift by the Charge Nurse on duty. If a medication aide or licensed nurse is behind, the Charge Nurse will be responsible for helping ensure medications are administered in a timely manner. The Quality Assurance Nurse will review the ?Administration of Medications? policy with all medication aides and licensed nurses every six months. The Quality Assurance Nurse will complete a medication pass audit on all medication aides and licensed nurses once per quarter, or more often if deemed necessary based on the results of the audit."