VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Willows at Meadow Branch
1881 Harvest Drive
Winchester, VA 22601
(540) 667-3000

Current Inspector: Jill James (540) 418-2631

Inspection Date: May 14, 2020 and May 15, 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 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

1. Please note to consistently complete the "appropriateness of Placement" form at admission, six months later and at the annual review time for all individuals residing in the memory care unit. 2. Have the physicians consistently provide parameters for the use of as needed/PRN medication. 3. Please report to licensing as soon as you are able to obtain a health and fire inspection. 4. Provide training for staff that a check mark does not indicate the effectiveness of an as needed medication - symptoms should be described when administering and an indication they have subsided when determining effectiveness.

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 5/13/2020 and was concluded on 5/15/2020. The administrator was contacted to initiate the inspection. The administrator reported that the current census was 59. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident files including medication records, health notes and physician orders. Four staff records plus background checks for those individuals employed after the last inspection were reviewed.They included certification and training verification. Health care oversight, dietary oversight and pharmacy oversight were also reviewed. The facility provided a letter indicating that a current health and fire inspection could not be obtained at this time due to the health pandemic. Fire and emergency drills were available for review as was a staff schedule. Information gathered during the inspection determined non-compliance with applicable standards or law, and two violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-200-B
Description:	Based on review of care notes during a desk review facility staff provided services outside their scope of practice or training at least three times. Staff wrapped or re-wrapped the legs of resident B on 3/30, 4/7 and 4/21/20 which is outside the scope of practice for direct care staff including medication aides as per Board of Nursing guidelines.
Plan of Correction:	Scope of practice will be reviewed with all applicable staff and documented accordingly. They will further be instructed to reach out to facility nurse or outside service nurse should the issue arise again. The administrator assumes responsibility for arranging training and monitoring for future compliance.
Standard #:	22VAC40-73-650-A
Description:	Resident A has an insulin order which indicates that the physician should be notified if the glucose test indicates a result of below 60 or above 350. There is no indication when insulin should be held. Based on a review of medication administration records and related notes for April, 2020 the resident did not receive insulin on 4/14,19,22 or 28. Blood sugars were observed to be 68,46, 52,51 and there is no indication that the physician was contacted for direction. This is further documented with an "X" or check mark in the box asking if physician was notified on the diabetic monitoring sheet. There are also multiple blanks on the diabetic monitoring sheet related to blood glucose results or amount of insulin given.
Plan of Correction:	All applicable staff will receive additional training as it relates to diabetic monitoring documentation and insulin administration in general. The physician will be contacted to determine at what low point he feels the insulin should be held. The administrator assumes responsibility for arranging the training and follow up monitoring to ensure future compliance.