VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Chesterfield
11200 W. Huguenot Road
Midlothian, VA 23113
(540) 898-1205

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Aug. 14, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

The inspector was on site on 08/14/2019 responding to a complaint alleging noncompliance regarding medication administration. Upon the arrival of the inspector the facility Administrator and designated staff person were not on site. The inspector informed facility staff the purpose of the inspection. Upon the arrival of the designated staff person the inspector again discussed the purpose of the inspection. The designated staff person informed the inspector that the Administrator had a scheduled day off. Facility records were reviewed for compliance and interviews were conducted with facility staff. The noncompliance revealed as a result of the complaint investigation is contained within this report. Based on the review of facility records and interviews conducted the complaint is valid. The inspector discussed with the designated staff person the need for key facility staff to attend ALF-Phase II Critical, Health and Safety standards review training. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and returned it to me within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions please feel free to contact me at (804)662-9774 or by e-mail at Angela.r.reaves@dss.virginia.gov if you have any questions. The inspection on this day was conducted between the approximate hours of 8:00a.m and 11:30a.m

Violations:

Standard #:	22VAC40-73-150-C
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted with facility staff #s 1 and 2, on 08/14/2019, the Administrator failed to ensure compliance with the facility's own policies and procedures. Evidence: Resident #1-Documented date of admission 06/20/2019 The facility's PP-61050-Medication Management (VA) document that was submitted for the inspector's review on 08/14/2019 noted the following: (1)-On page one, number 1-b) " If the Resident uses the Branch's preferred pharmacy, a signed copy of the Pharmacy Agreement must be kept in the Resident's record." Facility staff #s 1 and 2 both stated during interviews that the resident does use the facility's preferred pharmacy to fill and refill his prescribed medications. Upon request the facility did not submit for the inspectors' review documented evidence that such an agreement had been signed or that the document was in the resident's record. (2)-On page one, number1-d)-"If the Resident uses the Branch's preferred pharmacy, the Branch will request a refill of all prescription medications managed by the Branch when the quantity of medication on hand is enough for seven days." The facility's MAR charting for July 2019 notes that facility staff documented that the resident was not administered five (5) dosages of the prescribed medication Combivent. Upon request the facility did not submit for the inspector's review documented evidence that an order had been placed with the facility's preferred pharmacy per facility policy. However, facility staff did submit for the inspector's review documentation that an order for the prescribed medication Combivent was not made until 08/01/2019.
Plan of Correction:	FACILITY RESPONSE- "The following measures will be taken to ensure that the violation does not reoccur: a) An In-service was done with all the medication Aides on 8/22/19. They have been instructed to always re-order medications not in the community's medication re-order cycle when the medications have seven days? worth left. (b) The nurse coordinators will check medication quantity during weekly audits. (c) In-Service will be conducted with all medication aides by 9/17/19 about what the expectations are for medication re-ordering. They are to place medication order forms in the nurse coordinator?s box for review every day. Persons responsible to implement and monitor corrective measure to ensure compliance ? Nurse Coordinators"
Standard #:	22VAC40-73-190-C
Complaint related:	No
Description:	Based on a review of facility records and an interview with facility staff on 08/14/2019 the facility Administrator failed to ensure that prior to being placed in charge, the staff member was informed of and received training on his duties and responsibilities and provided written documentation of such duties and responsibilities. Evidence: During interviews facility staff #1 stated that she was the designated staff person in charge on 08/14/2019 and that the facility Administrator who had a scheduled absence had not provided her with documented instructions of her duties and responsibilities for the day.
Plan of Correction:	FACILITY RESPONSE- "The following measures will be taken to ensure that the violation does not reoccur: Copies of duties and responsibilities will be given to designated staff persons in charge when the Director or designated manager is not in the Branch. Signed copies of forms of what is expected of a Designated staff person in charge will be placed in Medication Aides files by 9/30/19. A frame with the names of the designated staff persons is always in the front entrance of the community. Note: The Assisted Living Medication Aide on duty is in charge when the management staff are not around. Persons responsible to implement and monitor corrective measure to ensure compliance ? Director"
Standard #:	22VAC40-73-290-A
Complaint related:	No
Description:	Based on a review of facility records and an interview with facility staff on 08/14/2019, the facility failed to maintain a written work schedule that includes the names and job classifications off all staff working each shift, with an indication of whomever is in charge at any given time. Evidence: Upon request the facility's July 2019 staff work schedule that was submitted for the inspector's review on 08/14/2019 is not documented to identify the names, job classification and work schedule for facility staff #1 and the facility Administrator.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-B
Complaint related:	No
Description:	Based on observation and interviews conducted with facility staff on 08/14/2018 the facility failed to implement a procedure for posting the name of the current on-site person in charge. Evidence: The facility's daily shift assignment document that was submitted for the inspector's review dated 07/30, 31/2019 under the heading Manger on Duty and Nurse On Call is blank and does not have identify anyone by name.
Plan of Correction:	The following measures will be taken to ensure that the violation does not reoccur: - A corrected written work schedule has been done to reflect the names, job classification, and shifts of all the staff working in the building at every point in time. This corrected schedule was presented to the inspectors on 8/28/19. The correction that was recommended was done the same day (that is change job title CMA to RMA). - A frame with the names of the designated staff persons is always in the front entrance of the community. Note: The Assisted Living Medication Aide on duty is in charge when the management staff are not around. - Starting from 8/15/19, the names of the Manager on Duty and the name of the nurse On-call will be written on the daily assignment sheets. 8/15/19 Persons responsible to implement and monitor corrective measure to ensure compliance ? Director ? Director?s designee
Standard #:	22VAC40-73-450-A
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with facility staff on 08/14/2019, the facility failed to ensure that a preliminary plan of care was developed for a resident on or within seven days prior to the day of admission. Resident #1-Documented date of admission 06/20/2019 Upon request the facility did not submit for the inspector's review documented evidence that a preliminary plan of care was developed for the resident. Two different documents; Service Assessment and a Service Plan that were submitted for the inspector's review were both dated 06/24/2019, four days after the resident's 06/20/2019 date of admission.
Plan of Correction:	FACILITY RESPONSE- "The following measures will be taken to ensure that the violation does not reoccur: The service plans written when residents' move-in, is the comprehensive service plan. Starting 8/15/19 nurse coordinator will write "Comprehensive" on all initial service plans. Persons responsible to implement and monitor corrective measure to ensure compliance ? Nurse Coordinator ? Director"
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with facility staff on 08/14/2019, the facility failed to ensure that resident Individualized Service Plan (ISP) were signed and dated by the resident or his legal representative. The plan shall also indicate any other individuals who contributed to the development of the plan, with a notation of the date of contribution. The title or relationship to the resident of each person who was involved in the development of the plan shall be included. These requirements shall also apply to reviews and updates of the plan. Evidence: Resident #1-Documented date of admission 06/20/2019 Upon request to review the resident's comprehensive ISP facility staff submitted to the inspector a Service Plan dated 06/24/2019 that was not signed by the resident or a legal representative.
Plan of Correction:	FACILITY RESPONSE- "The following measures will be taken to ensure that the violation does not reoccur: - A general audit of all residents' charts was done on 8/20/19 and will be on-going, to ensure that all residents or their legal representatives sign and date their Individual Service Plans (ISP). The names of all contributors to the plans have also been added. Moving forward the Director or her designee will ensure that all parties involved in ISP developments sign and date as required by this standard. - Attempts made to contact family members to sign the ISPs will be documented on the ISP signature page. Persons responsible to implement and monitor corrective measure to ensure compliance ? Director ? Nurse Coordinator
Standard #:	22VAC40-73-680-A
Complaint related:	Yes
Description:	Based on interviews with facility staff on 08/14/2019 the facility failed to ensure that only persons who are licensed, registered, or acting as medication aides on a provisional basis as specified in 22 VAC 40-73-670 administered drugs to those residents who are dependent on medication administration as documented on the UAI. Evidence: Resident #1-Documented date of admission 06/20/2019. The resident's 06/04/2019 Uniform Assessment Instrument assessed the resident as being dependent in medication administration. Under the heading Medication Administration notes- "Administered/monitored by professional nursing staff." A handwritten entry notes " RMA, LPN" indicating the facility staff that would be administering the resident's medication. Facility staff #2 stated during the interview conducted on 08/14/2019 that a family member of resident #1 took the prescribed medication Combivent from the medication room without permission and administered the medication to the resident.
Plan of Correction:	FACILITY RESPONSE- "The following measures will be taken to ensure that the violation does not reoccur: (a) All medications will be kept in sight of medication aides and nurses during every med pass. (b) Family members will not be allowed into the medication room during med pass (c) The medication room door will be closed during medication or treatments administration Persons responsible to implement and monitor corrective measure to ensure compliance: ? The nurse coordinators. ? Director
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on the review of facility records and interviews conducted with facility staff, the facility failed to ensure that medications were 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: Resident #1- Documented date of admission 06/20/2019 The facility's medication administration record (MAR) charting for July 2019 notes "Medication unavailable pharmacy notified "for the prescribed medication Combivent on 07/30/2019 at 8:00p.m; and on 07/31/2019 at 8:00a.m, 12:00p.m, 4:00p.m.
Plan of Correction:	The following measures will be taken to ensure that the violation does not reoccur: (a) Medication audit completed on 9/5/19. Audits will be conducted weekly on both medication carts in the building (b) Medication and cart audit reports will be filed in binders and reviewed by Director weekly. (c) Nurse Coordinators and charge nurse will go over medication administration documentation during every cart and medication audits. Persons responsible to implement and monitor corrective measure to ensure compliance: ? The nurse coordinators. ? Director
Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on the review of facility records and interviews conducted with facility staff on 08/14/2019 the facility failed to ensure that any medication errors or omissions were documented as required on the medication administration record. (MAR) Evidence: Resident #1-Documented date of admission 06/20/2019 The resident's MAR charting for July 2019 is documented on the front indicating that the resident's 8:00a.m, 9:00a.m and 4:00p.m medications were administered. However, facility staff documented on the back of the same MAR on July 29th at 9:16a.m "resident refused AM meds due to appt."
Plan of Correction:	FACILITY RESPONSE- "The following measures will be taken to ensure that the violation does not reoccur: - In service was done with the ALF?s medication aides on 8/22/19 about the right way to document medication errors and omissions. - An audit of all residents? files was completed by the Director on all residents? files on 9/6/19 to make sure that all residents who use the ALF?s preferred pharmacy have these pharmacy agreements in them. Audits will be done monthly on new residents pharmacy agreements as they come into the Branch. Persons responsible to implement and monitor corrective measure to ensure compliance: ? Director ? Nurse Coordinator
Standard #:	22VAC40-80-120-E-2
Complaint related:	No
Description:	Based on observation and interviews conducted on 08/14/2019 with facility staff the facility failed to ensure that the findings of the most recent inspection of the facility was posted. Evidence: Facility staff #1 confirmed that the 10/17/2018 renewal inspection was not posted at the facility.
Plan of Correction:	FACILITY RESPONSE- "The following measures will be taken to ensure that the violation does not reoccur: The renewal inspection report for 10/17/18 and the report of the inspection conducted on 8/14/19 has been put in a frame at the entrance of the community. This was done on 8/15/19".