VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Jefferson
900 North Taylor Street
Arlington, VA 22203
(703) 516-9455

Current Inspector: Alexandra Roberts

Inspection Date: May 8, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused monitoring inspection was conducted on 5/8/19 (10:45 AM - 11:30 AM) to follow-up on a high-risk violation that was cited on 2/22/19. Medication carts were inspected and resident records were observed. The violation was discussed and an exit meeting was held. Areas of non-compliance are identified on the violation notice. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Based on documentation, the facility failed to ensure that medications are administered in accordance with the physician's instructions. Evidence: Cranberry Concentrate/Vitamin C capsules, ordered 2/11/19 for Resident #1, were not present during the medication cart inspection. Resident #1's medication administration record (MAR) indicated that the medication was not administered on 5/7/19 or 5/8/19.
Plan of Correction:	The Cranberry Concentrate/Vitamin C capsules were obtained for Resident #1 and family agreed to have the pharmacy supply this medication moving forward. The physician was notified that the medication needed to be special ordered by the pharmacy and would not be available for several days. The resident had no negative outcome due to the medication not being available for administration between 5/7/19 and 5/15/19. The Resident Care Director audited medications provided by family members on 5/13/19 to verify that medications ordered were available for administration. No discrepancies were found during the audit. Refresher training will be conducted by the Resident Care Director for nurses and medication aides regarding the Pharmacy Use policy for residents/families choosing to provide medications from a pharmacy other than the facility pharmacy (Omnicare). A letter will be mailed to residents/families using an alternate pharmacy to re-educate them that they are responsible for providing refills at least 5 days prior to completion of the existing supply. If refills are not received 5 days prior to completion of the existing supply in appropriately labelled packaging, facility staff will order a 5-day supply from Omnicare, billed to the resident/family, until refills are received. Over the next three months, LPNs/RMAs assigned to med pass will audit carts daily to identify medications nearing completion for re-order. The Resident Care Director or designee will audit orders and medications for residents whose medications are provided by family members weekly to confirm that the medications ordered are available for administration. The results of these daily and weekly medication audits will be reviewed at Quality Assurance / Performance Improvement meetings. During and at the conclusion of the three months, the QAPI committee will re-evaluate and initiate necessary actions or extend the review period. The Executive Director and/or Administrator are responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.