VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Poet's Walk of Leesburg
102 Desmond Plaza
Leesburg, VA 20175
(571) 224-9516

Current Inspector: Jacquelyn Kabiri (703) 397-3017

Inspection Date: Nov. 29, 2022

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 8:14 am on 11/29/2022 and exited at 1:25 pm on 11/29/2022. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 11/1/2022 regarding allegations in the area(s) of staffing and supervision, and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 57 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 Number of staff records reviewed: 1 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Observations by licensing inspector: LI observed medication administration. Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations of non-compliance with standard(s) or law were resident care and related services. A violation notice was issued; any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based upon a review of records and interview with a collateral contact, the facility failed to implement the medication management plan 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 manger to avoid missed dosages. Evidence: 1.According to the physician?s orders, Resident #5 was prescribed Acitretin Capsule, 10mg to be given one time a day for 124 days. The order was written by the physician on 9/27/2022. 2. According to the November MAR, the medication was not available for administration on the following dates in November: 1st, 3rd, 4th, 6th, 7th, 8th, 9th, 10th, 11th, 12th, 13th, 15th, 16th, 17th, 18th, 19th, 20th, 21st, 24th, 25th, 26th, and 29th. 3. The collateral contact reported to LI on 11/30/2022, that ?after a review of pharmacy delivery logs and speaking with pharmacy staff and resident POA, the medication was never delivered to community.?
Plan of Correction:	Medication Aides and Nurses will follow the rules of proper prescription fill through community pharmacy. Staff have been counselled on appropriate steps to ensure medication is ordered and follow up with the pharmacy during and after deliveries in a timely matter. Our community will have monthly Med Tech evaluations, and quarterly skills checks. We will continue to monitory physician?s orders, pharmacy upgrades and audits.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based upon a review of records, interviews, and observation made by the Licensing Inspector (LI) the facility failed to ensure that medications shall be 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: 1. According to the Medication Administration Record (MARS), Resident #1 is to be administered Artificial Tears Solution (eye drops), 1 drop into both eyes at approximately 9 am and 6pm. 2. During observation of medication administration on 11/29/2022 at approximately 8:36 am, LI observed Staff #1 remove the Artificial Tears medication from the medication cart but did not observe Staff #1 administer the medication to Resident #1. 3. LI interviewed Resident #1 at approximately 8:55 am on 11/29/2022 and questioned Resident #1 if his eye drops had been administered. Resident #1 responded ?no, not yet.? 4. LI interviewed Staff #1 at approximately11:35 am on 11/29/2022 and asked if Resident #1 had received the eye drops. Staff #1 responded ?no, I forgot. I did not want to administer the eye drops while he was at breakfast.? 5. According to the November 2022 MAR, Resident #3 is to be administered Calmoseptine Ointment, which is to be applied to both groins at approximately 8am, 2pm, and 10pm. According to the November 2022 MARS, the medication was not administered on 11/3/2022 at approximately 2pm.
Plan of Correction:	Staff #1 has been counselled on administration time and the importance of following the physician?s order. All medication aides have been counselled on the importance of following the physician?s orders and dedicated time for administration. Moving forward, our community will have monthly Med Tech evaluations, and quarterly skills checks. We will continue to monitor physician?s orders, pharmacy upgrades and audits.
Standard #:	22VAC40-73-680-H
Complaint related:	Yes
Description:	Based upon a review of records and interviews, the facility failed to ensure that at the time medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over the counter and dietary supplements. Evidence: 1. LI reviewed the November 2022 Medication Administration Record (MAR) for Resident #1 at approximately 11:00am on 11/29/2022. According to the MAR, Resident #1?s Artificial Tears (eye drops) was administered at approximately 9am on 11/29/2022. 2.Based on interview with Staff #1 at approximately 11:35 am on 11/29/2022, Resident #1 had not yet been administered the 9 am dosage of Artificial Tears (eye drops).
Plan of Correction:	All medication aides have been counselled on the importance of following physician orders and dedicated time for administration. Moving forward, our community will have monthly Med Tech evaluations, and quarterly skills checks. We will continue to monitor physician?s orders, pharmacy upgrades, and audits.