VIRGINIA DEPARTMENT OF SOCIAL SERVICES

COMMONWEALTH SENIOR LlVING AT CHURCHLAND HOUSE
4916 West Norfolk Road
Portsmouth, VA 23703
(757) 483-1780

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: April 22, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This was an unannounced focused monitoring inspection to follow-up on violations cited during the previous inspection. The inspection was conducted by the Licensing Inspector from the Eastern Regional Office on April 22, 2019 from 10:34 AM until 2:22 PM. There were 69 residents in care. During the inspection resident and staff records were reviewed, to include a review of Medication Administration Records. A discussion was held regarding valid physician orders, communication with the pharmacy as well as with physicians and other prescribers. Also discussed reviewing all forms, specifically admission forms, to ensure accuracy and completion. Remember telephone orders must be signed by a physician within 14 days. The facility received violations under Personnel and Resident Care and Related Services. The violations were discussed with the Administrator throughout the inspection and during the exit interview. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must indicate how the violation will be or has been corrected. Just writing the word "corrected" is not acceptable. The plan of correction should include: 1. Step(s) to correct the noncompliance with the standard 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Reyna Rios at (757) 353-0430.

Violations:

Standard #:	22VAC40-73-260-A
Description:	Based on record review and interview, the facility failed to ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad or fire department. Each direct staff member who does not have current certification in first aid shall receive certification within 60 days of employment. Evidence: 1. Staff #3?s date of hire was 01-24-2019 as a Nurse Aide. Review of staff #3?s record with staff #6 revealed staff #3 did not have First Aid certification in the record, required within 60 days of employment at the facility. 2. Staff #5?s date of hire was 08-23-2017 as a Nurse Aide. Review of staff #5?s record revealed staff #5 had a first aid/CPR certification obtained in June 2017 from the National CPR Foundation and not from one of the organizations mentioned. 3. During interview, staff #6 acknowledged staff #3? missing first aid certification and staff #5?s first aid/CPR certification was not obtained from one of the aforementioned organizations.
Plan of Correction:	Staff #3 has taken a CPR/First Aide training class on 4-25-19 which makes her compliant with this regulation. Staff member #5 has taken a CPR/First Aide training class on 4-25-19 through the American Safety and Health Institute which makes her complaint with this regulation. The Business Office Manager (BOM) will complete a full team member file audit by 5-30-19 to ensure all team members are in compliance with this regulation. BOM, or designee, will conduct random monthly chart audits to ensure adherence to first aid training requirements.
Standard #:	22VAC40-73-650-A
Description:	Based on record review and interview, the facility failed to ensure no medication was started, changed or discontinued by the facility without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter and sample medications. Evidence: 1. During review of resident #1?s record, the resident had a Visit Summary note in the record dated 02-25-2019 which stated, ?Recommend we change Cymbalta to Zoloft vs. Lexapro to help more with behavior changes?. The bottom of the visit summary note page, listed the following under ?medication list?: ?Sertraline HCL 50mg, as directed-1/2 tabe PO daily x2 weeks then 1 tab PO qhs, 30 days?. The visit summary note was not signed or dated by a physician or other prescriber. a. Review of resident #1?s February 2019, March 2019, and April 2019 Medication Administration Records (MARs) revealed the facility started administering Sertraline (Zoloft) ? tab one time per day for weeks on 02-27-2019 and then 1 tab one time per day at bedtime starting on 03-14-2019 until 04-22-2019. The facility was unable to provide a signed order for the Sertraline (Zoloft). b. During interview, staff #2 acknowledged that the Visit Summary dated 02-25-2019 was not signed by the physician and did not include a valid order. Staff #2 also acknowledged that the facility has been administering Sertraline to the resident since 02-27-2019. 2. Further review of resident #1?s record revealed the resident had an order for Duloxetine (Cymbalta) 30mg for Depression ?2 capsules by mouth one time a day at bedtime? with a start date of 11-10-2017, per the April 2019 MAR. The April 2019 MAR indicated that the Duloxetine (Cymbalta) was discontinued on 04-10-2019. When asked to see the order to discontinue the medication, staff #2 provided Licensing Inspector with a telephone order form dated 04-10-2019 to discontinue Cymbalta 30mg. The order was written and signed by staff #2 however, was not signed by a physician or other prescriber. The last administration date for the Cymbalta was 04-09-2019. a. During interview, staff #2 acknowledged the Cymbalta was discontinued on 04-09-2019 without a signed order from the physician.
Plan of Correction:	Resident Care Director ((RCD) received a signed order from resident #1?s neurologist to discontinue the Cymbalta on 4-24-19. RCD has a signed order for the Zoloft 1 tab PO qhs effective 4-23-19 by resident?s NP. RCD, or designee, will complete a resident chart audit to ensure compliance with this regulation by 5-24-19. RCD or designee will conduct monthly random chart audits to ensure compliance with this regulation.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications were administered in accordance with the physician?s or other prescriber?s instructions. Evidence: 1. During review of resident #2?s record, the resident had a physician?s order dated 01-31-2019 for Memantine (Namenda) 10mg 1 tab two times a day for 30 days. The March 2019 and April 2019 Medication Administration Records (MARs) revealed the Memantine 10mg was administered to the resident longer than 30 days, for the month of March 2019 until April 22, 2019. 2. Further review of the March 2019 and April 2019 MARs revealed the initial start date of the Memantine was 08-19-2018, to be administered for 30 days. 3. A treatment plan in the record dated 08-24-2018 listed the Memantine (Namenda) 10mg, and documented the plan of care as ?continue current drug regimen indefinitely?. However, the physician?s order sheet indicated for the Memantine to be administered ?for 30 days?. The facility did not have documentation of clarification obtained from the physician to determine if the medication was to be discontinued after 30 days or to be continued indefinitely. 4. During interview, staff #2 acknowledged the Memantine was still being administered to the resident. Staff #2 stated that the treatment plan in the record indicated to ?continue indefinitely? therefore additional clarification was not obtained.
Plan of Correction:	Resident Care Director (RCD) received an order clarification for the Namenda on 4-23-19 which states to continue the Namenda, 10mg 1 tab BID, indefinitely. This order was signed by the neurologist. RCD, or designee, will complete a resident chart audit to ensure compliance with this regulation by 5-24-19. RCD or designee will conduct monthly random chart audits to ensure compliance with this regulation.