VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Oak Assisted Living at Petersburg
590 Flank Road
Petersburg, VA 23805
(804) 861-6977

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Aug. 27, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS

Comments:

A non-mandated focused monitoring inspection was initiated on 8/24/2021 and concluded on 8/27/2021. An intensive plan of correction and a risk profile follow-up was conducted by the department in the areas of Staffing and Supervision, Resident Care and Related Services and Building and Grounds. The administrator was contacted by telephone to conduct the inspection. The licensing inspector emailed the administrator a list of documentation required to complete the inspection. The licensing inspector conducted an on-site observation at the facility on 8/27/2021. An exit interview was conducted with (the Administrator and Director of Nursing) on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. 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.

Violations:

Standard #:	22VAC40-73-640-D
Description:	Based on an on-site observation the facility failed to maintain a current pharmacy reference book, drug guide or medication handbook available to staff who administer medications. Evidence: Staff #2 located a 2016 Pill Book in the medication cart however it was dated 2016.
Plan of Correction:	1) Facility immediatdely ordered (2) copies of 2022 Drug Reference guide from out pharmacy partner. Guides delivered 8/28/21 and placed in carts accordingly. 2) As a redundancy, Spring Oak ordered additional copies of Drug guides that were delivered on 8/29/21 to retain as a back-up copy. 3) Pharmacy representative will in-service all medication aides on availability and use of current drug resource guide located on the med carts in conjunction with our Electronic Medical Rcord Drug guide. DON or designee will audit medication carts daily x5 days, weekly x4 weeks then monthly times 2 months to ensure Drug Reference guides are available and staff are aware of how to utilized them in conjunction with our Electronic Medical Record Drug Guide. Expected Date of Completion: 9-10-21.
Standard #:	22VAC40-73-660-A-2
Description:	Based on an on-site audit of the medication cart controlled substances were not kept in a locked container within the locked cart. Evidence: Upon review of the medication cart the locked section of the cart designated for narcotics (Schedule II drugs) was broken. Narcotic medications are stored in the medication cart but are unable to be double locked. Staff #2 stated the pharmacy (Family Care) had been notified about this but responded that due to the pandemic they were unable to come out to perform a medication cart audit. The facility recently contacted them again and is waiting for them to respond.
Plan of Correction:	1) Pharmacy contacted 8/28/21 to request narcotic box for medication cart. 2) Pharmacy delivered new narcotic box for cart on 9/3/21. DON or designee will conduct an inservice for all medication aides to ensure they are aware of 22VAC40-73-(6)-660-A-2 standard and proper procedures for new narcotic drug box being implemented on medication cart. 3) DON or designee will audit cart and narcotic boxes daily x 5 days, then weekly x 4 weeks, then monthly x 2 months to ensure that schedule II medications are appropriately double locked. 4) Expected Date of Completion 9/10/21.
Standard #:	22VAC40-73-680-M
Description:	Based on an audit of the medication cart PRN medications were not available. Evidence: Resident #1 The PRN medications Acetaminophen 325 mg two (2) tablets and Loratadine (Claritin) (1) 10 mg tablet listed on the August 2021 MAR were not available in the medication cart. Resident #2 The PRN medication Nitroglycerin 0.4 one (1) tablet to be given sublingually listed on the August 2021 MAR was not available in the medication cart.
Plan of Correction:	PRN Tylenol and Claritin were immediately reordered for resident #1. PRN Nitroglycerin was immediately reordered for resident #2. All medications were delivered 8/28/21 and remain available for PRN use. Resident #1 and Resident #2 had no adverse effects as they had not requested nor indicated use for these PRN medications during this time. DON contacted NP and Pharmacy to verify all fax numbers being utilized for refill requests, an error was identified and immediately corrected. 2) DON or pharmacy representative will conduct an in-service for all Medication Aides to ensure they reord any medications that need to be reordered on the 24-hour communication log. DON also implemented new policy to ensure pharmacy includes number of refills on all medication labels. 3) DON or designee will audit medication carts daily x 5 days, then weejkly x4 weeks, then monthly x2 months to ensure that all PRN medications are available, properly labeled for the speciic resident and properly stored. 4) Expected Date of Completion 9/10/21.