VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Joseph C. Thomas Center
3939 Daugherty Road
Salem, VA 24153
(540) 380-6527

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Feb. 20, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 02/20/2024 from 09:15 AM until 02:30 PM 02/21/2024 from 09:15 AM until 12:30 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-560-F
Description:	Based on observation and staff interview, the facility failed to ensure that resident records were treated confidentially. EVIDENCE: 1. During day 2 of the on-site renewal inspection, this Licensing Inspector (LI) was performing a physical plant walk-through and LI observed the uniform assessment instrument (UAI) and the individualized service plan (ISP) for resident 9 were laying face-up on top of the Dogwood unit medication cart at 11:05 AM. 2. Upon this observation, LI observed staff 6 to be in the Dogwood unit common area, with another staff member, hanging decorations. This LI brought the UAI and the ISP to staff 6 who admitted to leaving the documents on top of the Dogwood unit medication cart and resident 9 admitted having the knowledge that by leaving resident 9?s UAI and ISP out on the cart they could be accessible by anyone, which is a violation of record confidentiality.
Plan of Correction:	All staff members in-serviced on HIPAA / privacy practices/ confidentiality.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and staff interview, the facility failed to ensure that medications were administered in accordance with physician?s or other prescriber?s instructions. EVIDENCE: 1. The record for resident 3 contained physicians orders that were signed on 01/23/2024 which ordered the following medication with instructions: NORVASC TABLET 5 MG ?Give 1 tablet by mouth one time a day for elevated BP hold for SBP less than 120?. 2. The documentation on the February 2024 medication administration record (MAR) for resident 3 indicated that the NORVASC TABLET 5 MG was administered at 08:30 AM despite the blood pressure readings that were recorded on the following dates: 02/01/2024 with a BP of 118/63, systolic blood pressure (SBP) being 118; 02/05/2024 with a BP of 118/73, SBP being 118; 02/14/2024 with a BP of 119/65, SBP being 119; and 02/19/2024 with a BP of 119/61, SBP being 119. In addition, the February 2024 MAR did not contain BP readings on 02/02, 02/06, 02/10, 02/16, and 02/20 but the Feb MAR indicated that the NORVASC TABLET was still administered on those dates. 3. An interview with staff 7 indicated that there are no other notes or exception documentation for those dates to show that the medication was withheld per physician instructions.
Plan of Correction:	All Medication staff in-serviced on Medication Management Plan, the 7 rights to Medication Administration, including correct documentation and the correct way to document medications with parameters.