VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Green Valley Manor
1011 Pennsylvania Avenue
Winchester, VA 22601
(540) 450-5642

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: Nov. 10, 2020 , Nov. 13, 2020 and Nov. 18, 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 63.2 General Provisions. 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. Discuss with physician establishing a baseline measurement for resident G and including that baseline in the order for monitoring; 2. Discuss with physician handling of notification of refusals and potential discontinuation of those medications after a given time period; 3. Documentation as it relates to physician notification should be included on the medication administration records(MARs) even if it is via nurse as per policy. Can note that nurse notified to discuss with physician; 4. Vitals check includes monthly weight but it is not included on the MAR with temperature, respiration and blood pressure. Request the pharmacy add an additional line to the MAR for weights to be recorded so they do not have to be recorded on a separate sheet; and 5. Discuss with pharmacy to remove extra "amount" line noted with insulin as discussed with nurse and administrative assistant.

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 11/10/2020 and concluded on 11/23/2020. The new administrator was contacted by email to initiate the inspection. The administrator reported that the current census was 34. The inspector emailed the administrator a list of things required to complete the inspection. The inspector reviewed three resident charts including notes and an additional eight medication records. Three staff records plus the record for the new administrator were reviewed that included training, background checks for all 15 employees, any certification requirements and staff scheduling. The inspection also included review of fire and health inspections, emergency drills, health care, dietary and pharmacy over site all submitted by the facility to ensure documentation was complete. It was noted that fire inspections were not conducted in the county for facilities that had not had previous issues. The facility did receive a notice that their next fire inspection should occur around January 8, 2021. Information gathered during this renewal inspection determined non-compliance with three applicable standards or law, and the violations were documented on the violation notice issued to the facility. These were reviewed with the administrator and administrative assistant. It is understood that due to the risk rating they received a focused inspection related to the violations will occur in sixty days. The facility is further aware that should these violations not be addressed and corrected resulted in additional violations the next step could be adverse enforcement. Thank you to staff and administration for your patience and assistance during this desk review process. You will be notified by mail regarding your renewal status following review by the licensing administrator. Should you have additional questions or concerns please call (540) 332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on remote inspection review of a sample of resident medication administration records (MARs) medications were not 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. Due to space constraints within the violation notice specific examples for residents E and J are recorded and on a separate listing along with the MAR as supporting documentation within the record. This information was provided to the facility with the violation notice. Resident A: Physician orders indicate a separate set of "hold" parameters for each of the three medications prescribed for high blood pressure. Documentation indicates that "hold" parameters were not followed in respect to each medication but rather the parameters related to the first medication were applied to the other two medications in some cases and in others they were simply held or administered incorrectly: Metoprolol - 10/27/20 8am Blood pressure is recorded but medication not given noting ?out of parameter? ? blood pressure (BP) was 120/66. Parameter is <120 or <60. 11/3/20 7PM Medication was administered - BP was recorded as 100/78 - hold parameter states hold if SBP<120 or DBP<70 Resident C: Has a sliding scale for use before meals and a five unit dose for after meals which is to be held if blood glucose level <150. 5 units of insulin were documented as given after the meal 11/4/20 as per parameters but it appears the same blood glucose level was used for before and after the meal. 5 units were not given after the meal on Nov 5 as new blood glucose level did not meet parameters for administration however documentation indicates that 5 units of insulin were given before breakfast. No insulin was required from the sliding scale before the meal 11/5/20. Resident D: Physician's order for lorazapam indicates is to be used for anxiety. MAR documentation November 9,2020 indicates used for agitation. Resident E: Physician orders indicate a sliding scale for insulin with specific parameters for administration. Based on MAR documentation insulin was not consistently administered as per the parameters outlined. There is also an order for a specific dose of insulin (4 units Novolog flex pen 100U/ML) to be given prior to meals That order does not have "hold" paraments. Based on MAR documentation insulin was "held" with reason not given "parameter not met" or less than the prescribed dosage was given. Resident J: Physician order indicates four (4) units of Humalog Kwikpen100U/ml is to be given before breakfast and dinner along with a sliding scale. There is also an order for seven (7) units along with a sliding scale before lunch. The sliding scale has specific parameters for administration and holding. The four and seven unit portion of the order do not. Documentation indicates that those units were held noting "parameter not met".
Plan of Correction:	1. Nurse will review all orders with hold parameters with physician to determine if consistency can be established for medications ordered with the same diagnosis to be addressed. 2. For insulin orders the physician will be requested to review and add hold parameters as applicable. 3. All staff administering medication will attend mandated refresher training in insulin administration and documentation with a particular focus on the sliding scale insulin and adhering to individual medication hold parameters. 4. All staff administering medication will attend mandated refresher training on overall MAR documentation and identifying and recording the need for and effectiveness of an :as needed"/PRN medication. 5. The administrator will monitor the MARs weekly and document that monitoring for 60 days and then twice a month thereafter. Counseling and additional training will be provided to those administering medication as situation is identified through this process. Correction will begin immediately with all staff having received training by the date indicated. The administrator and administrative assistant assume responsibility for correction and future compliance. They will coordinate training with the nurse consultant for the facility. All training will be documented and maintained in the staff record.
Standard #:	22VAC40-73-680-I
Description:	Based on review of a random sample of resident medication administration records (MARs) staff administering medication failed to consistently document blood glucose levels or the amount of insulin given for residents C, E and J. Blood pressures were not consistently documented for resident A. Due to space constraints within the violation notice specific examples for residents E and J are recorded and on a separate listing along with the MAR as supporting documentation within the record. This information was provided to the facility with the violation notice.
Plan of Correction:	1. All staff administering medication will attend mandated refresher training in insulin administration and documentation with a particular focus on the sliding scale insulin, documentation related to any and all medication that have hold parameters. No medication should be indicated as being held without supporting documentation. 2. All staff administering medication will attend mandated refresher training on overall MAR documentation and identifying and recording the need for and effectiveness of an "as needed"/PRN medication. 3. The administrator will monitor the MARs weekly and document that monitoring for 60 days and then twice a month thereafter. Counseling and additional training will be provided to those administering medication as situation is identified through this process. The administrator and assistant administrator assume responsibility for correction and future compliance. They will coordinate training with the nurse consultant for the facility. All training will be documented and maintained in the staff record. Correction to begin immediately with all staff having completed training by the date indicated.
Standard #:	22VAC40-90-40-B
Description:	Based on a review of staff records and background checks for all fifteen employees the facility failed to follow up ensure they had obtained a background check on or prior to the 30th day of employment. This was applicable to staff hired from June, 2020 to October 5, 2020 (staff C,D,E, I and N). Requests had been filed at the time of hire but the administrator failed to ensure there had been receipt or documentation indicating any follow up contact and a delay on the part of the state police due to the pandemic state. The administrator and administrative assistant verified via a phone interview that they had failed to monitor receipt of the background checks and were resubmitting immediately while also setting up the on line system.
Plan of Correction:	The new administrator is working with the state police to set up the electronic submissions system to ensure immediate results and avoid this issue in the future. In the interim all background check requests were resubmitted overnight as per instructions from the state police immediately upon notification of the problem by licensing inspector. Background checks are being faxed to licensing inspector as received and have all been returned by state police as of this writing, including those hires after October, 2020.