VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hermitage Roanoke
1009 Old Country Club Road, N.W.
Roanoke, VA 24017
(540) 767-6800

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

Inspection Date: April 7, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

The LI for Hermitage Roanoke conducted an unannounced monitoring investigation on 04/07/2022 from a facility self reported incident. Facility documentation and resident medication administration records were reviewed. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations cited can be found on the violation notice. Please respond back to your LI with your plan of correction within 10 days of receipt of this notice. If you have any questions or concerns please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on a review of facility documentation, medication administration records (MARs) and narcotic count logs, the facility failed to ensure that medications were administered in accordance with physician's instructions. EVIDENCE: 1. A facility incident report dated 04/02/2022 and updated 04/06/2022 has documentation that on 03/31/2022 at 8:20am a Duragesic patch prescribed for resident 1 was placed on resident 2. This was discovered by staff person 1 during the morning medication pass on 04/01/2022 and the incorrect patch was removed from resident 2. 2. The March 2022 MAR for resident 1 has documentation that the residents Fentanyl patch order is for 25mcg/hr transdermally every 72 hours. The March 2022 MAR for resident 2 has documentation that their Fentanyl patch order is for 12mcg/hr transdermally every 72 hours.
Plan of Correction:	Medications are being administered per physician?s instructions. Clinical team members certified to administer medications have been educated on the facility medications management plan and appropriate processes. Agency staff will receive training as they are assigned to the community. Director of Nursing, or designee, will conduct weekly audits of all medication carts to ensure medications are given per physician?s instructions. Executive Director, or designee, will audit all controlled substance count documents monthly to ensure continued compliance. Executive Director, or designee, will audit all medication carts monthly to ensure continued compliance.