VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Highland House
3501 Longdale Furnace Road
Clifton forge, VA 24422
(540) 862-4271

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: June 21, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-80 COMPLAINT INVESTIGATION.

Technical Assistance:

To ensure that the facility had a thorough understanding of standards, the licensing inspector and the Administrator had a discussion regarding standards 440-D, 450-C, 450-E, and 520.

Comments:

A non-mandated complaint inspection was initiated on 06/21/2021 and concluded on 06/25/2021. A complaint was received by the department regarding allegations in the areas of resident care and related services, building and grounds, and staffing levels for mixed population. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The licensing inspector conducted an on-site observation at the facility on 06/22/2021. An exit interview was conducted with the Administrator on 06/25/2021 where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or laws; however, information gathered during the inspection determined violations with applicable standards or laws and violations can be seen on the violation notice.

Violations:

Standard #:	22VAC40-73-650-B
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements identified the diagnosis, condition, or specific indications for administering each drug. EVIDENCE: 1. The record for resident 1 contained a signed physician?s order, dated 04/23/2021, for ?Alendronate Sodium 70 MG Take 1 Tablet By Mouth 1st Thing In Morning Once Weekly (FRI), No Brft, Caff, OJ, Other Meds & Remain Uprite X30MIN?. The physician?s order did not identify the diagnosis, condition, or specific indications for administering the drug Alendronate Sodium 70 MG.
Plan of Correction:	Administrator contacted resident?s physician to obtain an order to add the diagnosis to the Alendronate order on 6/25/2021.
Standard #:	22VAC40-73-680-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to ensure that medications were administered in accordance with the physician?s or other prescriber?s instruction. EVIDENCE: 1. The record for resident 1 contained a signed physician?s order, dated 04/23/2021, for ?Alendronate Sodium 70 MG Take 1 Tablet By Mouth 1st Thing In Morning Once Weekly (FRI), No Brft, Caff, OJ, Other Meds & Remain Uprite X30MIN?. 2. The June 2021 medication administration record (MAR) for resident 1 did not contain documentation that this medication was administered to resident 1 on Friday June 11, 2021.
Plan of Correction:	The administrator will review Medication Management plan with all RMA?s on 6/28/21 and monitor MAR?s weekly to ensure that medications are properly signed off.