VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Regency at Augusta
43 Pinnacle Drive
Fishersville, VA 22939
(540) 213-4400

Current Inspector: Jill James (540) 418-2631

Inspection Date: Dec. 2, 2020 , Dec. 4, 2020 and Dec. 7, 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 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Questions answered and discussions occurred on the following: 1) The secured unit activity person must complete the required training within six months of hire (1120.F). Please submit training certificates to licensing inspector upon completion. 2) It is the facility's responsibility to ensure the stat box remains current (expired 11/30/20 and was replaced on 12/2/20). 3) Make sure all staff carefully review all paperwork to ensure all information is accurate and complete.

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 12/2/20 and concluded on 12/7/20. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 20 (eight on assisted living unit and 12 on the secured unit). The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident, two contract staff and three staff records. Selected sections of one resident and two staff records were also reviewed. The inspector also reviewed fire drill log sheets, activities calendars, menu, staff schedules, first aid kit, dietary/medication/healthcare oversights, required postings, resident council meeting minutes, stat box, staff rounds log sheets, as well as other documentation. A virtual tour of various areas of the facility, including the secured unit, was conducted along with a review of various documents. Information gathered during the inspection determined non-compliance with tuberculin skin assessments and implementation of the medication management plan, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based upon documentation and an interview, the facility failed to ensure two of the three tuberculin skin assessments (TBs) were completed prior to the first day of work. Evidence: 1) Staff B (hired 9/23/20) had a TB assessment form signed and dated as completed on 9/23/20; staff C (hired 7/13/20), had a TB assessment form signed and dated as completed on 7/14/20; however, neither of the forms indicated the results of the assessments. Section I, titled "Screen for symptoms and check all that apply," was left blank, including the option for "none", Section III, titled "Findings (check all that apply) was also left blank, including the option of no risk factors for TB infection. 2) On 12/4/20, the licensing inspector (LI) interviewed the administrator who stated the information was left blank as the nurse must have forgotten to check the appropriate sections and just signed the form.
Plan of Correction:	TB assessments were completed immediately on the staff members in question to bring them into compliance. Facility will implement and put into practice a checks and balance that will ensure all charts are audited by the business office manager, prior to staff start date, to ensure compliance. Executive director and director of health and wellness will audit all staff records monthly, along with the business office manager, to ensure compliance is maintained.
Standard #:	22VAC40-73-640-A
Description:	Based upon documentation and an interview, the facility failed to implement the medication management policy by ensuring all information on the medication administration records (MARs) was transcribed accurately. Evidence: 1) The November and December MARs indicated allopurinol was to be given in the morning (AM); however, the signed physician's order indicated the medication was to be given at lunch time; the MARs listed the diagnosis for atorvastatin as hyperlipidemia; however the signed physician's order listed the diagnosis as dyslipidemia; the MARs listed the diagnosis for trazadone as depression; however, the signed physician's order listed the diagnosis as dementia; NOTE: The effective date for these medications was 11/18/20. 2) On 12/7/20, the LI interviewed the administrator who also reviewed the MARs and stated the MARs and orders did not match.
Plan of Correction:	The pharmacy was contacted immediately to have the time changed to the correct time and the diagnoses corrected, according to the physicians' orders. The director of health and wellness, along with the memory care director, will audit the MARs the first of each month to ensure the proper diagnoses and time of administration are included for all medications. Director of health and wellness/memory care director will audit the charts for new orders to ensure that all new orders have been transcribed properly (immediately upon receipt), including each having the proper diagnosis and time of administration to match the order. These will also be sent to the pharmacy to ensure compliance.