VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Virginia Home for Adults
2701 Border Road
Chesapeake, VA 23325
(757) 545-6219

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: April 28, 2020 and April 29, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 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 April 28, 2020 and concluded on April 29, 2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 51. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 4 resident records, 4 staff records, staff schedules, health inspection, fire inspection, fire and emergency evacuation drills, healthcare oversight, dietary oversight, emergency preparedness/response plan review, and staff emergency exercises submitted by the facility to ensure documentation was complete. The following was discussed: tuberculosis screening forms completion, healthcare oversight completion, and resident agreement specifics on meals and fees. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. Additionally, please contact me if you would like to review your Violation Notice via phone.

Violations:

Standard #:	22VAC40-73-650-B
Description:	Based on record review and interview, the facility failed to ensure physician or other prescriber orders included the diagnosis, conditions, or specific indications for administering each drug. Evidence: 1. Resident #2?s physician?s orders dated 04-14-20 documented Voltaren 1% Topical Gel ? 1 application Topically twice a day, every day(s); however, the specific indications for administering the drug was not specified. 2. Resident #4?s physician?s orders dated 04-14-20 documented Hydrochlorothiazide 25 mg Tab ? 1 tab by mouth once a day, every day(s); however, the diagnosis was not specified. 3. Staff #1 acknowledged the physician?s order did not provide the specific indications for administering resident #2?s medication. Staff #1 acknowledged resident #4?s physician?s order did not include the diagnosis for administering the medication.
Plan of Correction:	Administrator reviewed order for resident 2 order states, "for burn treatment". This residents burns were on most of his body and order says for burn treatment. RMA has been asked to call the doctor to ask if he would be more specific on body parts ointment is applied and write it on a new order. Going forward Administrator has advised RMA manager to remind doctor at the time of visit if possible to give more details on the prescriptions or on Physician orders. Resident 4 order states "take for Fluid". Administrator met with RMA Manager HT. RMA stated fluid was the diagnosis the doctor wrote. Administrator advised RMA to call the doctor and see if he can give a more detailed diagnosis for this medication. Going forward the RMA will attempt to remind the Dr. to give detailed diagnosis on all orders. Administrator will be mindful to look for specific diagnosis going forward when doing monthly reviews.
Standard #:	22VAC40-73-970-E
Description:	Based on record review and interview, the facility failed to ensure the fire and emergency evacuation drills recorded included the time of the drill. Evidence: 1. The fire and emergency evacuation drills conducted September 2019, October 2019, November 2019, December 2019, and January 2020 did not provide the time that the drills were conducted, only the shifts that the drills were conducted during. 2. Staff #1 acknowledged the drills did not contain the times of the drills were not documented on the aforementioned drill dates.
Plan of Correction:	Manager transcribes our evacuation information from our monthly desk calendar and failed to carry over the exact time on each shift that it was done. Sept. drill was at 4 pm, Oct drill was at 11 pm, Nov drill was 10 am, and Dec drill was 4 pm, form has been updated. This information was noted on the monthly calendar. Administrator will be sure to review monthly fire drill and Emergency Evacuation form going forward to ensure all information is documented. Manager has been spoken to on 5/4/2020 about the importance of time and details. Monthly drills are done rotating between shifts normally near change of shift so 1 additional staff is present to time the drills.