22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION
Technical Assistance:
None
Comments:
Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/01/2024, 1:30pm-3:30pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 6/23/2024 regarding allegations in the area of resident care. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed:0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 3
Additional Comments/Discussion: none
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported some, but not all of the allegation(s); area(s) of non-compliance with standard(s) or law were: 22VAC40-73-640-A, 22VAC40-73-680-D, 22VAC40-73-680-H, 22VAC40-73-150-C
A violation notice was issued; any violation(s) not related to the (complaint(s) 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 Jessica Gale, Licensing Inspector at 540-571-0358 or by email at Jessica.Gale@dss.virginia.gov
Based on record review and staff interview, the facility failed to report to the regional licensing office within 24 hours of any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. Resident 1 was hospitalized according to the hospital discharge summary from 6/11/2024-6/14/2024 following an incident that occurred at the facility on 6/11/2024. 2. Staff 1 stated ?I don?t believe it was? when asked if the incident was reported to the licensing office.
Plan of Correction:
The Executive Director and / or Wellness Coordinator will assure timely reporting to all agencies as required by 22VAC40-73-70-A.
Standard #:
22VAC40-73-640-A
Complaint related:
Yes
Description:
Based on record review and staff interview the facility failed to implement a medication management plan including methods for verifying that medication orders have been accurately transcribed to medication administration records (MARs) within 24 hours of receipt of a new order or change in an order. Evidence: 1. Resident 1 had physicians orders dated 7/2/2024 to discontinue all medications prior to 7/2/2024. 2. The July 2024 MAR shows Humalog 100u/ml start date 6/14/21, Lispro insulin Kwikpen 100u/ml start date 6/26/2024,and Touejo 300u/ml start date 6/26/2024, were not stopped until 7/9/2024.
Plan of Correction:
The Administrator will collaborate with the Wellness Coordinator and representative from Wellness Concepts for implementation of routine Order / MAR reconciliation to assure the MAR is accurate and consistent with provider orders. The Wellness coordinator will verify that all new orders received from providers are accurately reflected on the MAR weekly over a four week period of time.
Standard #:
22VAC40-73-680-H
Complaint related:
Yes
Description:
Based on record review and staff interview, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents. Evidence: 1. The June MAR for resident 1 did not contain any documentation of medication administered between the hours of 8am to 12pm on June 25, 2024. 2. Staff 1 stated an employee from the other facility came over to administer the medications that day and must not have documented medications administered.
Plan of Correction:
The Administrator will collaborate with the Wellness Coordinator for weekly audits of documentation of medication administration to assure documentation is complete and correct, to be conducted over a four week period of time.
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
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