VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hidden Treasures Residential Living
201 Dodge Street
Stuarts draft, VA 24477
(540) 490-1093

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: April 21, 2020

Complaint Related: No

Areas Reviewed:

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 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Criminal History Record Report

Technical Assistance:

1. Need to catch up staff training when Covid 19 emergency state is over; 2. Get clarification from physician for use of Clobetasol orders indicating where the "affected area" is; and 3. When completing the uniform assessment instrument (UAI) related to medication administration always check the second box indicating lay person which is what medication aides are classified as under the Board of Nursing despite their registration.

Comments:

This inspection was conducted by licensing staff using an alternative remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 4/21/2020 and concluded on 4/21/2020. David Reedy was contacted by telephone to initiate the inspection. David Reedy reported that the current census was 10. The inspector emailed David Reedy a list of items required to complete the inspection. The inspector reviewed five resident records which included medication administration records, five staff records including training records, the current staff schedule, and outside inspection reports and related drill documentation as applicable submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with an applicable standard or law, and violation was documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-680-I
Description:	Based on a review of a sample of medication administration records (MARs), the following was missing or not addressed: 1. Resident A - the order for oxygen was not included on the MAR although resident was receiving; 2. The orders relating to as needed or PRN medication did not include what to do if symptoms persist; and 3. When a medication was not effective after administration there was no documentation of follow up by the staff with the physician as to what to do to relieve the symptoms for the individual.
Plan of Correction:	Administrator will contact the physician(s) to add an order of what to do if symptoms persist for ll individuals. Administrator will review the cited issues with staff and document accordingly. When the COVID 19 state of emergency is lifted the administrator will request additional training for staff by the pharmacy nurse. Administrator assumes responsibility for correction and future compliance. The date represents the initial meeting with staff and request sent to physicians as a true compliance date cannot be projected at this time.