VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Blacksburg Campus
3400 South Point Dr.
Blacksburg, VA 24060
(540) 317-3463

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: July 19, 2022

Complaint Related: No

Comments:

? 22VAC40-73-(1) GENERAL PROVISIONS ? 22VAC40-73-(2) ADMINISTRATION AND ADMINISTRATIVE SERVICES ? 22VAC40-73-(3) PERSONNEL ? 22VAC40-73-(4) STAFFING AND SUPERVISION ? 22VAC40-73-(5) ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS ? 22VAC40-73-(6) RESIDENT CARE AND RELATED SERVICES ? 22VAC40-73-(7) RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS ? 22VAC40-73-(8) BUILDINGS AND GROUND ? 22VAC40-73-(9) EMERGENCY PREPAREDNESS ? 22VAC40-73-(10) ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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: 07/19/2022 Start: 10:00am conclude 11:55am The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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: 07/19/2022 Start: 10:00am conclude 11:55am 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 07/15/2022 regarding allegations in the area of medication administration. Number of resident records reviewed: 1 Number of staff records reviewed: 0 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 Crystal B. Mullins, Licensing Inspector at (276) 608-1067 or by email at crystal.b.mullins@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based on the review of a resident record, the facility failed to include hospice care as a provided service on the on the ISP. EVIDENCE: 1. The ISP dated 02/04/2021 did not include hospice and the specifics of the services they provide to Resident #1.
Plan of Correction:	The resident ISP was updated on 7/19/22. ISPs to be updated upon any significant change in condition. DON/Designee to perform ISP audits, at random, monthly for 3 months and intermittently moving forward as a preventative measure. [sic]
Standard #:	22VAC40-73-450-F
Description:	Based on staff interview and review of a resident record, the facility failed to update the ISP (Individualized Service Plan) at least once every 12 months. EVIDENCE: 1. Documentation review and interview with Staff #1, confirm the most up to date ISP for Resident #1 was dated 02/04/2021.
Plan of Correction:	The resident ISP was updated on 7/19/22. ISPs to be updated annually or upon any significant change in condition. DON/Designee to perform ISP audits, at random, monthly for 3 months and intermittently moving forward as a preventative measure. [sic]
Standard #:	22VAC40-73-680-D
Description:	Based on staff interview and documentation, the facility failed to administer medications in accordance with the physician 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. EVIDENCE: 1. Resident #1 is prescribed Hydromorphone HCL 1mg/mL, give 0.5mL every four hours as needed for pain or shortness of breath. Based on staff interview and documentation, the facility failed to administer medications in accordance with the physician 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. EVIDENCE: 1. Resident #1 is prescribed Hydromorphone HCL 1mg/mL, give 0.5mL every four hours as needed for pain or shortness of breath. 2. According to a statement from Staff #1, on 07/14/2022 at approximately 2:28pm Staff #6 administered Resident #1 5.0mL (ten times the prescribed dose) to residents that are not capable of determining when medication is needed of Hydromorphone after she complained of back pain. 3. Staff #7 documented on 07/14/2022 in the facility Interdisciplinary Notes at 3:30 pm she checked on Resident #1, she was lying in bed, her color was very pale, had oxygen on and was noted to be very diaphoretic and unresponsive. Again at 7:00pm Resident #1 was noted as being unresponsive but not diaphoretic. 4. During an interview with Collateral #1 she stated ?dose could have killed her? in regards to the 5.0mL dose of Hydromorphone and stated that facility staff should have notified Hospice of the discrepancy and the change in Resident #1?s condition. 5. Staff #2 discovered a discrepancy in the narcotic count for Hydromorphone for Resident #1 on 07/15/2022, it was discovered 45mL was the start dose of Hydromorphone. After Staff #6 administered the incorrect dose of 5.0mL, the balance was 40.0mL of Hydromorphone.
Plan of Correction:	Staff person involved in medication administration was removed from the position of medication administration on 7/19/22. Medication Administration meeting with Med Staff took place on 8/2/22. Regional Director of Resident Care and COO present at facility beginning 8/2/22 for increased monitoring and oversight of medication administration. Ongoing. Medication Administration training scheduled for 9/6/22 for all medication staff. Medication Administration oversight to be performed at random, moving forward, to ensure compliance. [sic]
Standard #:	22VAC40-73-680-E
Description:	Based on the review of a resident record, the facility failed to record pertinent information such as services ordered by a physician and provided by an outside agency and the resulting evaluations of progress. EVIDENCE: 1. Resident #1 receives hospice. On the day of inspection, 07/19/2022 hospice note in the file was dated 06/30/2022. 2. According to Staff #2, the hospice notes are kept by the company providing the service and left at the facility at the end of the month for which service was provided.
Plan of Correction:	On 7/19/22, DON requested and initiated Hospice notes to be left after each visit from provider. Notes to be placed in the Resident file by designated staff member(s). DON/Designee to monitor monthly for 3 months and intermittently moving forward as a preventative measure. [sic]
Standard #:	22VAC40-73-680-K
Description:	Based on the review of a resident record and the MAR (Medication Administration Record), the facility failed to obtain from the physician or other prescriber a detailed medication order when PRN (as needed) medication is administered by Based on the review of a resident record and the MAR (Medication Administration Record), the facility failed to obtain from the physician or other prescriber a detailed medication order when PRN (as needed) medication is administered by medication aides to residents that are not capable of determining when medication is needed EVIDENCE: 1. Resident #1 is prescribed Hydromorphone HCL 1mg/mL, give 0.5mL every four hours as needed for pain or shortness of breath; Acetaminophen 500mg tablet, take one tablet by mouth every six hours as needed for pain/fever; and Tramadol HCL 50mg tablet, take one tablet by mouth every four hours as needed for pain. The physician?s or other prescriber?s order does not include symptoms that indicate the use of the medication, the exact time frame the medications are to be given in a 24 hour period, or directions as to what to do if symptoms persist. 2. Staff #3, #4, and #5 which are medication aides at the facility, have administered the above PRN medications to Resident #1. 3. According to Staff #6, Resident #1 was able to ask for medications and express she was in pain until approximately two weeks ago, and stated now they have to look for facial grimacing or moaning and groaning as signs/symptoms that resident is in pain. 4. On the date of the inspection (07/19/2022) the LI attempted to speak with Resident #1 but she did not answer verbally; she did smile, open her eyes and nodded her head.
Plan of Correction:	Staff person involved in medication administration was removed from the position of medication administration on 7/19/22 PRN medications reviewed by Regional DORC/DON/Designee on 8/24/22 to verify that signs and symptoms of PRN medications are documented accordingly, standard reviewed with DON on 8/24/22. DON/Designee to perform Physician Order Sheet audits monthly for 3 months and intermittently moving forward to ensure that PRN medication signs and symptoms are appropriately documented. [sic]