VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Spring Arbor of Winchester
2093 Northwestern Pike
Winchester, VA 22603
(540) 662-6883

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: June 13, 2022 and June 29, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

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. Should you have any questions, please contact Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on document review, the facility failed to report to the regional licensing office within 24 hours, any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. On 06/06/2022, an incident report was received via email from the facility, reporting a medication error that occurred on 06/04/2022 indicating resident 1 was administered 80 units of Levemir by staff 3. The physician?s order for resident 1 is for 10 units of Levemir. Resident 1 was transported to the hospital via ambulance. 2. This report was not received by the regional licensing office within 24 hours.
Plan of Correction:	Protocols have been reinforced in the community for all major incidents to be reported by the Supervisor-In-Charge to the Resident Care Director or the Cottage Care Director as soon as possible, regardless of the day of the week. The Resident Care Director/Cottage Care Director or designee will notify the regional licensing office within 24 hour, regardless of the day of the week, of any major incident that has occurred which may affect or threaten the life, health, safety, or welfare of any resident. Following this survey, the Executive Director reviewed the 24 hour reporting requirements with appropriate Department Heads. In addition, an in-service on 24 Hour Reporting Protocols is scheduled to be conducted on 07/07/2022 by the Director of Quality and Education, targeted to the Resident Care Director, Cottage Care Director and Assistant Resident Care Coordinator.
Standard #:	22VAC40-73-680-D
Description:	Based on document review and interviews, the facility failed to ensure medications are administered in accordance with the physician?s 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 has the following order effective 05/03/2022: Levemir Flextouch 100units/ml-Inject 10 units subcutaneously two times a day for Diabetes Mellitus. 2. On 06/06/2022, an incident report was received from the facility indicating resident 1 received 80 units of Levemir at 7:45pm by staff 3 and was transported to the hospital by ambulance. 3. The current Virginia Board of Nursing medication aide curriculum states on page 49, the five rights of medication administration are the right client; the right drug; the right dose; the right route; and the right time. 4. The LI interviewed the Executive Director and the Resident Care Director on 06/13/2022 who confirmed resident 1 received 80 units of Levemir instead of the prescribed 10 units of Levemir on 06/04/2022 at 7:45pm by staff 3. 5. A review of the hospital discharge summary requested from the facility and received on 06/23/2022 indicates resident 1 was hospitalized for observation from 06/04/2022 through 06/06/2022.
Plan of Correction:	To ensure the "Five Rights" of medication administration are followed, random medication observations were completed by the Assistant Resident Care Coordinator/LPN with staff 3 on 06/10/2022, 06/24/2022, and on 06/30/2022. The Supervisor-In-Charge and/or the Assistant Resident Care Coordinator/LPN verified all insulin does pre-administration for staff 3 for a period of 30 days beginning on 06/06/2022 and ending on 07/06/2022. In addition, all LPNs and Medication Technician's received a Diabetic Testing and Insulin Administration in-service completed by the Assistant Resident Care Coordinator/LPN on 06/11/2022. Ongoing, Bayada In-House HH/Therapy RN will assist RCD and ARCC with ongoing Insulin Modules and Training on a quarterly basis. Safe Medication and Insulin Administration will also be focal topics during the documented Annual/Mandatory Medication Aide 4 Hour Refresher Class.