VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Hills Mt. Vernon
3709 Shannons Green Way
Alexandria, VA 22309
(703) 780-7100

Current Inspector: Nina Wilson (703) 635-6074

Inspection Date: June 9, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 complaint inspection was initiated on 6/09/2020 and concluded on 6/19/2020. A complaint was received by the department regarding allegations in the areas of medication management and communication with resident or legal representative(s). The was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law, and violations were issued. Any violations not related to the complaints but identified during the course of the investigation can be found on the violation notice. Areas of non-compliance are identified on the violation notice. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation and if you have any questions please call (703) 895-5627 or contact me via e-mail at jeannette.zaykowski@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-E
Complaint related:	Yes
Description:	Based on record review, facility failed to ensure that the individualized service plan shall be signed and dated by the facility designee, and by the resident or his legal representative; and these requirements shall also apply to reviews and updates of the plan. Evidence: 2/3 persons who developed (created) Resident #1's ISP dated 11/25/2019 did sign and date the ISP and the ISP was not signed and dated by the resident or legal representative; and an undated ISP in record that states "last service plan review completed 01/15/2020" was not signed and dated by any persons; and documentation of communication with resident or legal representative regarding Resident #1's ISP reviews and updates was not available.
Plan of Correction:	Facility will ensure that the individualized service plan shall be signed and dated by the facility designee, and by the resident or his legal representative; and these requirements shall also apply to reviews and updates of the plan. Identified Resident individualized service plan shall be signed and dated by the facility designee, and by the resident or his legal representative; and these requirements shall also apply to reviews and updates of the plan. Measures to prevent the non-compliance from occurring again: 100% Review of Residents individualized service plan signed/notified and dated by the facility designee, and by the resident or his legal representative; and these requirements shall also apply to reviews and updates of the plan. Person Responsible: DRC Or Designee.
Standard #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based on record review and interview, facility failed to ensure that no medication shall be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Evidence: Resident #1's record and Medication Administration Record (MAR) from 12/1/2019 through 6/4/2020 was reviewed and the following valid orders for LORazepam administered to Resident #1 were not available in record: 1) To discontinue LORazepam Tablet 0.5 MG (1/2 tab=0.25 MG) on or about 1/16/2020 as documented in December 2019 MAR and January 2020 MAR. 2) To start LORazepam Tablet 0.5 MG on or about 1/16/2020 as documented in January 2020 MAR, February 2020 MAR, March 2020 MAR, April 2020 MAR and May 2020 MAR. 3) To discontinue LORazepam Tablet 0.5 MG on or about 5/23/2020 as documented on January 2020, February 2020, March 2020 MAR, April 2020 MAR and MAY 2020 MAR. 4) To start LORazepam 0.5 MG (1/2 tablet) on or about 5/24/2020 as documented on May 2020 MAR. 5) To discontinue LORazepam Tablet 0.5 MG (1/2 tab) on or about 5/26/2020 as documented on May 2020 MAR. 6) To start LORazepam Tablet 0.5 MG (1/2 tab=0.25 mg) on or about 5/26/2020 as documented on May 2020 MAR and June 2020 MAR.
Plan of Correction:	Facility will ensure that no medication will be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber. Identified Resident order sent to Prescriber for reviewed and Signature. Measures to prevent the non-compliance from occurring again: 100% Audit of Residents medications/orders. Second Checks for all Orders. Daily Review of orders by DRC or Designee X 30 Days Weekly Review of Orders By DRC or Designee X 4 Weeks Person Responsible: DRC Or Designee.
Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on record review, physician or other prescriber orders, both written and oral, for administration of all prescription medications shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Evidence: Resident #1's record documents a prescription for LORazepam 0.5 MG dated and signed by provider on 11/14/2019 and does not document the diagnosis, condition, or specific indications for administering the drug.
Plan of Correction:	Facility will ensure physician or other prescriber orders, both written and oral, for administration of all prescription medications shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Identified Residents medications will shall include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. Measures to prevent the non-compliance from occurring again: All Residents medications will be include the name of the resident, the date of the order, the name of the drug, route, dosage, strength, how often medication is to be given, and identify the diagnosis, condition, or specific indications for administering each drug. 100% Audit by Date of Compliance Person Responsible: DRC Or Designee.
Standard #:	22VAC40-73-670-1
Complaint related:	No
Description:	Based on record review, facility failed to ensure that each staff person who administers medication shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. Evidence: Resident #1?s Medication Administration Record (MAR) from 12/1/2019 through 6/4/2020 was reviewed and 3/18 staff who documented medication administration between those dates were not licensed or registered according to the Standard. Staff #4, Staff #8 and Staff #13 records document Medication Technicians by Maryland and no documentation in record of registered with the Virginia Board of Nursing as a medication aide.
Plan of Correction:	Facility will ensure that each staff person who administers medication shall be licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. All identified Staff will licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. Measures to prevent the non-compliance from occurring again: Staff will licensed by the Commonwealth of Virginia to administer medications or be registered with the Virginia Board of Nursing as a medication aide. Person Responsible: DRC Or Designee.