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: June 23, 2022

Complaint Related: No

Areas Reviewed:

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

Technical Assistance:

Reviewed standard 220 regarding the requirements for agency and non-agency private sitters.

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: 6/23/2022 from approximately 9:30 am to 4:10 pm. 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 6/14/2022 regarding allegations in the area of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 64 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 3 (selected sections) Number of staff records reviewed: 4 (selected sections) Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 6 Additional Comments/Discussion: Narcotic count sheets and medications were reviewed for three residents. 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at Janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based upon documentation and an interview, the facility failed to ensure one of three residents? individualized service plans (ISPs) were signed by the resident or the resident?s legal representative. Evidence: 1. The ISP (updated 11/30/2021) for resident 1 was not signed by the resident or the resident?s legal representative. 2. On 6/23/2022, the licensing inspector (LI) interviewed staff 4 who stated the ISP had not been signed by the resident or the resident?s legal representative
Plan of Correction:	1. The resident?s ISP, updated 11/30/2021, will be signed by the resident or his or her responsible party. Other residents? ISPs will be audited to ensure signatures from the resident or residents? responsible parties. ISPs not signed by the resident or the residents? responsible party will be signed by one of them. 2. An ISP tracking tool will be created to ensure the resident or his or her responsible party signs the ISP. 3. The Executive Director and Director of Health and Wellness will be responsible for the implementation and monitoring of this plan. The Executive Director, or designee, will audit the ISP tracking tool monthly to ensure the resident or his or her responsible party signed the ISP. 4. Date by which plan of correction will be fully implemented and noncompliance will be corrected: Tuesday, July 26, 2022.
Standard #:	22VAC40-73-450-H
Description:	Based upon interviews, the facility failed to ensure the care and services specified in the ISP was provided to one of three residents. Evidence: 1. On 6/23/2022, the LI interviewed staff 5 who stated, ?Resident 1?s laundry is done twice a week and there are times when there is only one gown.? 2. On 6/28/2022, the LI interviewed collateral 1 who stated, ?I have seen her in the same gown where the wound dressing and gown were both saturated. They don?t clean her very well and she has had feces in her vaginal area.? 3. On 6/28/2022, the LI interviewed collateral 2 who stated, ?Sometimes I would find her not as clean and it looked like she had the same gown on Friday as she did on Tuesday.? 4. On 6/28/2022, the LI interviewed collateral 3 who stated, ?The last month or so has been worse than usual. She had drainage on her gown and feces in her vaginal area. Sometimes she has the same gown on Friday as she had on Tuesday. 5. The ISP (completed 11/30/2021) stated, ?Due to immobility and incontinence, resident 1 uses incontinent products and is to be changed and cleaned by staff. Check on her frequently such as during safety checks to ensure that she is clean and does not need her incontinent products changed. She is able to tell you if she needs assistance as well.? 6. The ISP also states, ?Resident 1 needs mechanical and physical assistance with dressing. Resident 1 is able to pick out her own clothes. Staff will need to dress resident 1. Services will be provided twice a day at the community.?
Plan of Correction:	1. This resident?s ISP will be reviewed and updated, if applicable, to ensure care and services specified in the ISP are provided. Direct care staff will be reeducated regarding how to follow a resident?s ISP and provide indicated care. 2. The Director of Health and Wellness, or designee, will review three ISPs per month and then observe direct care staff to ensure care and services specified in the ISP are provided. 3. The Executive Director and Director of Health and Wellness will be responsible for the implementation and monitoring of this plan. The Director of Health and Wellness will submit results of the ISP monthly audits, for three months, to ensure care and services specified in the ISP are provided, to the Executive Director for review. 4. Date by which plan of correction will be fully implemented and noncompliance will be corrected: Tuesday, July 26, 2022.
Standard #:	22VAC40-73-640-A
Description:	Based upon documentation and interviews, the facility failed to ensure implementation of the medication management plan. Evidence: 1. On 6/14/2022, the LI received a self-report that one pharmacy card with 30 tramadol were missing for resident 1. 2. On 6/23/2022, the LI interviewed the administrator and the health and wellness nurse and both stated the medication was received on 5/31/2022 by staff 6; however, staff 6 could not remember who she gave the medication card to or if she put the card in the medication room. 3. Under the section for ?Controlled Substances? the facility medication plan states, ?a. The pharmacy should be requested to send controlled substances separate from other medications. b. It is imperative that if there are any controlled substances present when medications are delivered that they are removed, logged, processed, and properly stored immediately. 5. Once the medications are logged, the meds are placed in the appropriate area of the med cart or overflow meds as appropriate.? 4. Page 7, Section 16, of the medication management plan also stated, ?All medications maintained within the building that fall under the DEAs schedule II ? V will be locked in a double lock box, the locks of which open with separate keys. These meds will be counted when delivered.?
Plan of Correction:	1. The Medication Management Plan will be reviewed and updated, if applicable. Based upon this review, and possible changes, staff will be reeducated according to Medication Management Plan. 2. Staff will be educated regarding necessary adherence to the Medication Management Plan, and how to do so. 3. The Executive Director and Director of Health and Wellness will be responsible for the implementation and monitoring of this plan. The Director of Health and Wellness, or designee, will submit documentation to the Executive Director verifying ongoing adherence to the Medication Management Plan. 4. Date by which plan of correction will be fully implemented and noncompliance will be corrected: Tuesday, July 26, 2022.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation and an interview, the facility failed to ensure one medication for one of three residents was administered according to the physician?s order. Evidence: 1. Resident 1 had a signed physician?s order for one 50mg tablet Tramadol twice a day. 2. The June 2022 electronic medication administration record (eMAR) was initialed and circled by the registered medication aides (RMAs) on duty for 6/7/2022 and 6/8/2022 for the morning and evening doses. The omission notes stated, ?Waiting for pharmacy deliver
Plan of Correction:	1. The medication for this resident was already replaced. Staff who administer medications will be reeducated regarding community procedures for accepting, managing, and storing controlled substances. 2. The Director of Health and Wellness, or designee, will review the EMAR five times per week to ensure no missed or held medications. The Director of Health and Wellness will submit results of the EMAR audits to the Executive Director for review. 3. The Executive Director and Director of Health and Wellness will be responsible for the implementation and monitoring of this plan. The Executive Director will review the EMAR audit results and address any noted concerns. 4. Date by which plan of correction will be fully implemented and noncompliance will be corrected: Tuesday, July 26, 2022.