VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tidewater Cove, Operated by Western Tidewater CSB
2536 East Washington Street
Suffolk, VA 23434
(757) 935-1415

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Oct. 7, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/07/2022 from 9:38 am to 10:30 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 09/06/2022 regarding allegations in the area(s) of: Resident Care and Related Services. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of staff records reviewed: 2 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on documentation and interview, the facility failed to implement their written plan for medication management which includes a plan for proper disposal of medication. Evidence: 1. On 09/01/2022, medications were found in the facility?s dumpster by staff at the facility. 2. The Medication Management Plan indicates the facility?s policy and procedures for the disposal of medications. ?Medications that are disposed of in the facility will be: crushed by a licensed nurse or RMA; logged on the Medication Disposal Form and witnessed by two nurses, a nurse and a RMA, or two RMAs; all disposed drugs shall be mixed with cat litter or coffee grounds and disposed of in a biohazard red bag.? 3. Staff #1 acknowledged the facility?s policy and procedure on the disposal of medications as noted in their Medication Management Plan were not followed.
Plan of Correction:	Tidewater Cove will remain in compliant with this regulation. All medical staff have been retrained on proper medication disposal protocol. Medications that are disposed of in the facility will be: crushed by a licensed nurse or RMA; logged on the Medication Disposal Form and witnessed by two nurses, a nurse and a RMA or two RMS?s; all disposed drugs shall be mixed with cat liter or coffee grounds and disposed of in a biohazard red bag. All medical staff have received in-service training on proper medication disposal protocols and the Medication Management Plan reviewed with each medical staff as well. All staff were provided a copy of the Medication Management Plan with the addendum that outlines how to properly ?Restock Medication Carts?.