VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Linden House
1250 Branchlands Drive
Charlottesville, VA 22901
(434) 973-0311

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

Inspection Date: Nov. 8, 2019

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

Comments:

On 11/08/2019 the assigned licensing inspector for the Central region was on site to conduct an unannounced renewal inspection. The facility Administrator was not on site upon the arrival but arrived shortly thereafter. A front desk representative was given an explanation of the purpose of the inspection. The inspector began the inspection on the facility?s safe and secure unit and explained the purpose of the inspection with the unit manager. A morning medication administration pass was observed on the facility?s assisted living program. Facility records notes that facility staff has recently participated in a medication administration refresher class. However, based on observation of the morning medication pass technical assistance was offered to the facility Administrator. A review of the noncompliance and a review of photographs taken were discussed during the exit interview. 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 was conducted on 11/08/2019 was conducted between the approximate hours of 8:53a.m and 1:20p.m.

Violations:

Standard #:	22VAC40-73-150-C
Description:	Based on observation, the review of facility records and interviews conducted with facility staff on 11/08/2019 the Administrator failed to oversee the day-to-day operation of the facility. Resident #11 (A)- Methods to ensure that each resident's prescription medications and any over-the-counter drugs and supplements ordered for the resident are filled and refilled in a timely manner to avoid missed dosages. Number 7b on the facility?s Medication Administration Plan that was submitted for the inspector?s review on 11/08/2019 in part notes: ? ?If a medication is not available at the scheduled time of administration, notification to the pharmacy via telephone and/or fax is implemented?. ? ?An extensive STAT box of medication is available on site if medications is unavailable due to extenuating circumstances.? ? Identified Pharmacy ?also provides the facility with a STAT medication process with a 4-hour turnaround time, 24-hour pharmacy services and back up local pharmacy service for any medication needed.? (B)- Methods to prevent the use of outdated, damaged, or contaminated medications. Number 12b on the facility?s Medication Administration Plan that was submitted for the inspector?s review on 11/08/2019 in part notes: ?Return of unused, unopened and or-expired medications to pharmacy may occur under certain conditions. For specific directions, contact Pharmacy?. A resident was administered medication that had expired two months prior to administration. The facility Administrator did not provide sufficient oversight to all staff responsible for medication administration to ensure proper implementation of the facility?s medication administration plan.
Plan of Correction:	FACILITY RESPONSE- "Facility Administrator will ensure that Wellness Director and Wellness staff who administer medications have reviewed the Medication Management Plan, including the protocol for removing expired medications from the Med Cart."
Standard #:	22VAC40-73-450-B
Description:	Based on the review of facility records with the facility Administrator and facility staff on 11/08/2019 the facility failed to ensure that a resident?s ISP was developed in conjunction with the resident?s case manager, health care providers, qualified mental health professionals, or other persons. Evidence: Resident #8-documented date of admission 09/11/2019. The resident?s 09/11/2019 ISP that was submitted for the inspector?s review in part notes ?Hospice nurse will visit weekly and social worker will provide support at least monthly.? The resident?s ISP was not documented to note the hospice agency?s participation in the development of the ISP. Upon request the facility Administrator did not submit for the inspector?s review documented evidence that the resident?s hospice agency participated in the development of the residents? 09/11/2019 ISP.
Plan of Correction:	FACILITY RESPONSE- "Hospice Plan of Care, signed by Hospice Nurse, was attached to the ISP on 11/08/19. Hospice Nurse will sign the ISP by 11/27/19. Facility Administrator will ensure that documentation is added to ISP to give evidence that outside service providers, POAs or resident legal representatives were invited to participate in the development of the Individualized Service Plan, and whether or not they responded or attended. A review of the ISP process will be conducted with all staff who participate in the development of ISPs by 12.10.19 Ongoing monitoring will occur during chart audits to ensure compliance."
Standard #:	22VAC40-73-680-D
Description:	Based on observation, the review of facility records and interviews conducted with facility staff on 11/08/2019 medications were not 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 # 11 The resident?s physician orders for November 2019 in part notes: Latanoprost Opth Soln 0.0005% ?Instructions: Administer 1 drop in each eye one time a day at bedtime for Glaucoma? Observation of the facility?s medication cart and the facility?s Electronic Medication Administration Records (E-MAR) charting for November 2019 with facility staff #s 5 and #6, and as evidenced by the photographs taken revealed the following: The tube of Latanoprost Opth Soln 0.0005% medication found in the facility?s medication cart had a label affixed that noted an expiration date of ?9/3/19?. For seven (7) days beginning 11/01-07/2019, facility staff #s 7, 8, 9, 10 and 11 administered the expired eye drops to resident #11. Later in the day during the 11/08/2019 inspection, the facility Administrator stated to the inspector that the new medication had arrived at the facility.
Plan of Correction:	FACILITY RESPONSE-"The facility notified the physicians and responsible parties of this situation on 11/08/19. The expired medication (eyedrops) was destroyed per protocol, and new replacement medication arrived from the pharmacy while the Licensing Inspector was on-site on 11/08/19. The medication carts have been audited again to ensure thet there are no further expired medications. The Wellness Director or designee will conduct a weekly med cart audit to ensure continued compliance".
Standard #:	22VAC40-73-680-H
Description:	Based on observation the facility failed to ensure that over-the-counter medication labeled with the resident's name until administered. Evidence: Observation of the facility?s medication cart on 11/08/2019 with facility staff #s 5 and 6 revealed a 1.7 FL ounce bottle of Liposomal Gluthathione that was not labeled with a resident?s name or room number.
Plan of Correction:	FACILITY RESPONSE- "The bottle identified was labeled with resident name and room number while the licensing inspector was at the facility. Facility Administrator will ensure that Wellness Director and Wellness staff who administer medications have reviewed the Medication Management Plan. All over-the-counter medications will be labeled prior to being placed in the med cart. Another 100% Med Cart Audit to ensure compliance shall by conducted by 12/10/19"
Standard #:	22VAC40-73-870-A
Description:	Based on observation on 11/08/2019 the faciity failed to ensure that the interior and exterior of the faciilty was maintained in good repair and kept clean and free of rubbish. Evidence: Resident #s 3 and 12 As evidenced by the photographs taken the carpet in the resident's rooms were observed to have debris build up and stained.
Plan of Correction:	FACILITY RESPONSE- "The carpets in the two apartments identified were shampooed on 11.08.19 and stains were removed. Debris (tissue and crumbs) were removed immediately. Facility Administrator shall ensure that full audit of all resident apartment is conducted by 11/22/19 to identify any carpet stains that need to be removed. Ongoing building audits will occur monthly. Facility staff have been reminded to notify housekeeping immediately if a resident has a stain or debris on carpet, or any other housekeeping needs."