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: June 20, 2024 and June 27, 2024

Complaint Related: No

Areas Reviewed:

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: 06/20/2024, 1:08pm to 2:05pm 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 06/14/2024 regarding allegations in the area(s) of: Resident care and related services, medication management plan and reference materials. Number of residents present at the facility at the beginning of the inspection: 75 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: n/a Number of interviews conducted with residents: n/a Number of interviews conducted with staff: 6 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on review of facility documentation and interviews with staff, the facility failed to implement a written plan for medication management including methods to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s medication management plan states: ?During shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off-going medication persons. The oncoming and off-going medication persons both sign off on the accurate counts of all narcotics on the Narcotic Administration Record.? 2. A physician?s order was provided on 01/25/2024 for resident #1 stating the following: Give morphine sulfate conc. 0.25mL under tongue Q 4 hr. PRN for pain, facial grimacing, moaning, or labored breathing, respiratory rate > 24. 3. On 06/12/2024 at 1500, a physician?s order was provided for resident #1 stating the following: Give morphine sulf. (conc) 20mg/mL, 0.5 mL under tongue Q 4 hr; Give morphine sulf. 0.5mL under tongue Q 2 hr PRN pain, grimacing, moaning or shortness of breath. 4. On 06/13/2024 a physician?s order was provided for resident #1 stating the following: D/C morphine conc. 0.25mL Q 4 hr PRN, order was changed to 0.5mL scheduled and PRN. 5. The controlled drug record for the medication noted in item #1 above states the prefilled morphine syringes (0.25mL=5mg) were received by the facility on 01/26/2024 and the amount documented as received was 60 prefilled syringes. 6. Per interview with staff #1 and staff #2, they counted the medication on 06/12/2024 at approximately 7am during staff changeover and there were 60 syringes counted. 7. Per documentation by staff #1 on the controlled drug record and the June 2024 Medication Administration Record (MAR), two 0.25mL syringes were administered to resident #1 on 06/12/2024 at 6pm as a scheduled medication per the order noted in item #2 above: Give morphine sulf. (conc) 20/mg/mL, 0.5 mL under tongue Q 4 hr. The amount remaining following administration was documented as 58 syringes. 8. Per interview with staff #2, she arrived to work at approximately 8:35pm on 06/12/2024 and staff #3 stayed until approximately 9pm on 06/12/2024. Staff #2 reports they did not count the 0.25mL morphine syringes during staff changeover as they were no longer being administered at that point due to the new orders requiring 0.5mL syringes. The 0.5mL syringes had been delivered to the facility and were being administered per physician orders per staff #2. 9. Per interview with staff #4, she and staff #2 ?did not count all three bags? of the 0.25mL morphine syringes during staff changeover at approximately 7am on 06/13/2024, but when she pulled the 0.25mL syringes from the cart later that day for disposal, she only counted 57 syringes, instead of the previously documented 58 syringes. She reports she counted the medication again with staff #5 and staff #6 and they counted 57 syringes as well.
Plan of Correction:	Administrator and DON held a Mandatory Meeting with all med management staff on June 14, 2024 to re-educate all staff on counting narcotics with every change in Med tech on the cart. Educating on the importance of the accuracy of this count. They will be informed that if the count is incorrect at any time, they must contact DON and Administrator immediately. All med staff were informed that if they are found not to have completed a count they will be immediately terminated. All med staff drug tested on June, 14, 2024. Administrator and/or DON will have begun daily audits of narcotic count books in the mornings and evenings daily. Administrator and/or DON will do narcotic counts on all med carts weekly. These audits will take place for 3 months and then randomly thereafter. [SIC]