VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Second Chance
524 Pisgah Church Road
Rice, VA 23966
(434) 392-9276

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 24, 2022

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 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:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 05/24/2022 12:00PM through 1:45PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 9 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on observation during medication cart audits, the facility failed to ensure that infection control policies that are consistent with the Centers for Disease Control and Prevention (CDC) recommendations were followed. EVIDENCE: 1. The facility?s infection control policy included the following statement on page 14 of 16, ?10. Ensure each glucometer is put in a separate storage case and labeled (case and Meter labeled) with the resident?s name before placing it in the storage area.? 2. The glucometer for resident 5, located in the facility?s medication storage cabinet, was not labeled with the resident?s name per CDC recommendations and the facility?s infection control policy.
Plan of Correction:	The Administrator and ALF Coordinator reviewed 22VAC40-73-100-C-2, the noted violation, and Second Chance?s Infection Control Policy regarding glucometers. The ALF Coordinator labeled the noted resident?s glucometer during the inspection and ensured that it was placed in the labeled storage container for the noted resident. The Administrator and ALF Coordinator reviewed the noted violation, Infection Control Plan, and CDC recommendations with all RMAs to ensure they understood the requirement of the glucometer itself in addition to the storage container needing to be labeled with no exceptions. The Administrator and ALF Coordinator will conduct monthly and weekly inspections of the glucometer and any new glucometers that may be ordered and received in the future to ensure each is labeled as required.
Standard #:	22VAC40-73-680-M
Description:	Based on observation of the facility?s medication storage containers and staff interview, the facility failed to ensure that medications ordered for PRN (as needed) administration were available at the facility. EVIDENCE: The record for resident 2 contained a physician?s order, dated 12/08/2021 ? 12/08/2022, for the following medications: Acetaminophen, SM Tussin, Cough drops, Chloraseptic spray, Chlorpheniramine, Tums, Simethicone, Loperimide, Milk of Magnesia, Triple anti-biotic ointment, Hydrocortisone Cream, and Vitamin A&D ointment. The aforementioned medications were not available at the facility during the on-site inspection and this was confirmed by staff 3.
Plan of Correction:	The Administrator and ALF Coordinator reviewed 22VAC40-73-680-M, the noted violation, Second Chance?s Medication Management Plan, and all current PRN orders on hand for all residents. The Administrator and ALF Coordinator reviewed the current PRN orders and yearly OTC forms. The ALF Coordinator contacted Bremo LTC Pharmacy to refill all noted PRN orders that were not on hand at the time of the inspections. In addition, the ALF Coordinator contacted each resident?s prescribing physician and requested new orders for all applicable PRNS rather than utilizing the OTC form that contained a list of potential OTC medications that may be needed. The Administrator and ALF Coordinator ensured that all PRN orders were reviewed and all medications prescribed were on hand or ordered for refill. The Administrator and ALF Coordinator reviewed the violation and medication management plan with all facility RMAs to ensure that PRN medications are refilled in a timely manner and on hand at the facility at all times per standard. The Administrator and ALF Coordinator will conduct monthly and bi-weekly audits of all PRN inventories as noted in previous plan of corrections above.