22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION
Comments:
Type of inspection: Complaint An on-site Complaint Inspection was conducted by two inspectors from the Peninsula Licensing Office. Ar (09:43 a.m.) dep (15:30 p.m) 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 6-20-24 regarding allegations in the areas of resident care and related services.
Number of residents present at the facility at the beginning of the inspection: 19 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 Number of staff records reviewed: Number of interviews conducted with residents: Number of interviews conducted with staff: 4 Observations by licensing inspector: Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 (Willie Barnes), Licensing Inspector at (757) 439-6815 or by email at willie.barnes@dss.virginia.gov
Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs.
Evidence: 1. On 7-2-24, resident #2?s uniformed assessment instrument (UAI) dated 6-19-24, dressing assessed as physical assistance, the individualized service plan (ISP) date 6-23-24 noted dressing as supervision, with cues provided. Transferring and toileting noted as independent, no help; the ISP noted mechanical help, grab bar for toileting and walker for transferring. Eating/feeding and walking assesses as supervision. The ISP noted resident feeds self and mechanical help, use of a walker for walking. Wheeling is not checked on the UAI and stairclimbing assessed as not performed. The ISP noted not performed for both needs, however, it did not note who and how the services would be performed. Mobility assessed as supervision, the ISP noted resident need for mechanical help of a walker and staff assistance. 2. Staff #1 acknowledged the resident?s, assessed needs and what was noted on the ISP did not agree.
Plan of Correction:
Resident Care Coordinator and Regional Director of Care will complete an audit for all current resident records to ensure that all resident UAI's match their ISP's. Audit will be completed by August 30, 2024. Going forward Executive Director will review all ISPs for compliance after being completed by Resident Care Coordinator.
Standard #:
22VAC40-73-640-A
Complaint related:
Yes
Description:
Based on documented reviewed and staff interviewed, the facility failed to ensure the accurate counts of all controlled substances.
Evidence: 1. On 7-2-24, during a medication complaint inspection, resident #2?s physician?s order dated 12-15-23 noted resident to take 0.25ml (0.5mg) Lorazepam every 2 hours as needed for agitation/anxiety/restlessness. The narcotic sheet noted 30 ml received by the facility on 12-19-23. Staff #5 administered the first dosage of 0.25 ml on 2-9-24 with a remaining count of 25 ml. Staff #5 also administered the second dosage on 4-20-24 with a remaining count of 24.00 ml. These were the only dosages noted on the narcotic sheet. Staff #3 and #6 noted on the narcotic sheet, ?corrected count 22 ml?. The record did not document any other administration of this prescribed Lorazepam. 2. Staff #1 and #2 acknowledged the count on the narcotic sheet was not accurately noted. 3. On 7-2-24, resident #1?s Controlled Drug Record noted on 2-7-24, staff received 30 dosage Lorazepam (0.5mg/25mg) syringes, ?apply topically to inner wrist twice daily as needed for agitation.? The label noted ?Discard after 3-8-24?. The first dosage was administered on 2-8-24. The staff members continued to administer the medication beyond the discard date. The narcotic sheet noted staff members administer the medication seventeen times (17) from 3-10-24 (11:15p) to 5-1-24 (8 p). Staff initialed and noted on the facility Controlled Drug Record, medication was ?completed 5-1-24?. The facility?s Controlled Drug Record for resident #1, noted on 4-23-24, staff received 30 dosage Lorazepam (0.5mg/25mg) apply 1 syringe topically to inner wrist twice daily as needed for agitation. The label noted, ?Discard after 5-21-24?. The first dosage was administered on 5-2-24 and the last dosage noted was administered on 5-22-24.
Plan of Correction:
All medication staff will be inserviced on proper medication administration policies, six rights of medication administration, and standards on medication pass times and documentation. Medication staff inservices will be completed by the Executive Director by August 30, 2024. Resident Care Coordinator will audit each medication cart twice weekly for the next two months to ensure all expired medications have been removed from the medication cart. Resident Care Coordinator or Executive Director will audit narcotic count sheets for each medication cart five times weekly for the next two months to ensure compliance.
Standard #:
22VAC40-73-680-C
Complaint related:
Yes
Description:
Based on record reviewed, document reviewed, and staff interviewed, the facility failed to ensure medications was administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule, except those drugs that are ordered for specific times, such as before, after, or with meals.
Evidence: 1. On 7-2-24, resident #1?s Controlled Drug Record noted resident?s Lorazepam on 5-27-24 scheduled for 8 a.m. was given at 10:00 a.m. and the 2 p.m. dosage was administered at 4 p.m. 2. Staff acknowledged the resident?s medication was not given within the facility?s one-hour before/one-hour after standard dosing schedule.
Plan of Correction:
All medication staff will be inserviced on proper medication administration policies, six rights of medication administration, and standards on medication pass times and documentation. Medication staff inservices will be completed by the Executive Director by August 30, 2024.
Standard #:
22VAC40-73-680-D
Complaint related:
Yes
Description:
Based on record reviewed, documented reviewed and staff interviewed, the facility failed to ensure that medications was administered in accordance with the physician?s or other prescriber?s instructions
Evidence: 1. On 7-2-24, during a medication complaint inspection, resident #1?s Controlled Drug Record noted on 5-24-24, staff received 42 syringe dosages of Lorazepam (0.5mg/ 25mg), apply 1 syringe topically to inner wrist three times daily X 14 days for agitation. The document noted the first dosage was administered on 5-24-24. The record noted the medication was administered on 6-8-24 and 6-9-24. 2. Staff #1 and #2 acknowledged the resident?s medication was administered beyond the prescribed time days.
Plan of Correction:
All medication staff will be inserviced on proper medication administration policies, six rights of medication administration, and standards on medication pass times and documentation. Medication staff inservices will be completed by the Executive Director by August 30, 2024.
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.
Find this content at:
http://www.dss.virginia.gov/facility/search/alf.cgi