VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Virginia Veterans Care Center
4550 Shenandoah Ave.
Roanoke, VA 24017
(540) 982-2860

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: Sept. 10, 2021 , Sept. 13, 2021 , Sept. 14, 2021 and Sept. 20, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

A renewal inspection was initiated on 09/10/2021 and concluded on 09/20/2021. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 18. The inspector emailed the Administrator and Assistant Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed two resident records, two staff records, activities calendar, menu, staff schedules, policies, fire and health inspections submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on 09/14/2021. An exit interview was conducted with on 09/16/2021, 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. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-290-A
Description:	290-A Based on document review, the facility failed to maintain a written work schedule that indicates who is in charge at any given time. EVIDENCE: 1. The written work schedule failed to show who was in charge the following times: night shift 8/22, 8/29, 8/29, day shift 8/30, night shift 9/4, 9/5, and evening shift 9/8, 9/9, 9/10/2021.
Plan of Correction:	1. The current work schedule has been corrected to show the person in charge of the unit. 2. The Unit Manager/Designee will check the work schedule daily to verify that it is correct and shows the staff member in charge. 3. Any issues with the daily work schedule will be reported to the quarterly QAPI meeting.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to address some assessed needs on comprehensive individualized service plans (ISP). EVIDENCE: 1. The UAI dated 2/19/2021 for resident 1 showed this resident is disoriented to Place, some of the time, and this is not addressed on the ISP dated 2/19/2021.
Plan of Correction:	1. The ISP for resident 1 has been reviewed and corrected to show disorientation to place some of the time. The corrected ISP has been reviewed with the resident. 2. All ISP?s will be audited to verify that any disorientation listed on the UAI is correctly documented on the ISP. 3. The ALF Unit Manager/Designee will audit all UAI/ISP on a quarterly basis to verify accuracy. 4. Audit results will be reported and reviewed at the quarterly QAPI meeting until resolved.
Standard #:	22VAC40-73-640-A
Description:	Based on document review, the facility failed to have some required sections in their written plan for medication management. EVIDENCE: 1. The facility's written plan for medication management did not address methods for verifying medications orders have been accurately transcribed to medication administration records with in 24 hours or receipt of a new order or change in order, methods to ensure that medication administration records are maintained as part of the resident's record, and methods to ensure that staff who administer medications meet current qualification requirements.
Plan of Correction:	1. The medication management policy has been reviewed and corrected to show methods for verifying medication orders have been accurately transcribed to medication administration records within 24 hours of receipt of a new order or change in order, methods to ensure that medication administration records are maintained as part of the residents record, and methods to ensure that staff who administer medications meet current qualification requirements. 2. Staff have been educated to all aspects of the medication management policy. 3. The Unit Manager/designee will audit orders 3 times a week for 4 weeks then 2 times a week for 4 weeks then prn to verify that the medication management policy is being followed. 4. Audits results will be reported and reviewed at the quarterly QAPI meeting until resolved.
Standard #:	22VAC40-73-650-E
Description:	Based on resident record review, the facility failed to have prescribers signed written orders in resident records. EVIDENCE: 1. Resident 2 was administered acetaminophen on 9/1/2021 and 9/2/2021 and the order signed on 3/21/2021 documents that this order has expired and is inactive. 2. The September 2021 medication administration record (MAR) for Resident 2 shows the following as needed (PRN) medications may be administered: fluticasone, Genteal eye drops, Imodium, docusate sodium, and emetrol solution. The medications were available to administer, and there are no signed orders for them.
Plan of Correction:	1. The medication administration record for Resident 2 has been reviewed and corrected to reflect only active signed physician orders. Medications have been audited to reflect the signed orders and any medications without signed orders have been destroyed per facility policy. 2. The medication administration record for all DOM residents has been reviewed and corrected to reflect active signed orders and medications have been audited to show the same with any medications without signed physician orders destroyed per facility policy. 3. All resident charts will be reviewed on night shift to verify that orders are transcribed correctly. 4. The Unit Manager/Designee will audit orders 3 times a week for 4 weeks then 2 times a week for 4 weeks and then weekly and prn to verify that orders are accurate and that any orders which have expired are removed from the medication administration record. 5. Audit results will be reported and reviewed at the quarterly QAPI meeting until resolved.
Standard #:	22VAC40-73-680-B
Description:	Based on observation and interview, the facility failed to keep medications in the pharmacy container until they were to be administered to the residents. EVIDENCE: 1. On 9-14-2021 at approximately 3:30 PM, approximately 12 to 15 souffle cups filled with medications were sitting on top of the medication cart. Staff 3 stated they were pre-poured and to be administered between 4 and 5 PM.
Plan of Correction:	1. ALF staff has been educated that medications must be kept in the pharmacy container until administered. 2. The Unit Manager/Designee will audit medication carts 3 times a week for 4 weeks, then 2 times a week for 4 weeks and then weekly for 4 weeks and prn. 3. Audit results will be reported and reviewed at the quarterly QAPI meeting until resolved.