VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Inspirit Hilltop Operator LLC
111 Denny Lane
Winchester, VA 22603
(540) 667-5323

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: May 14, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

This investigation was completed in response to a complaint received in the licensing office on 05/08/2019 relating to the allegation of medication mismanagement. The information gathered during this investigation supports the allegation, so the complaint is determined to be valid. Details of non-compliance can be viewed in the violation report section. Please complete the columns for "description of action to be taken" and "date to be corrected" for each violation cited on the violation notice. The plan of correction must include 1) steps to correct the non-compliance with the standard; 2) measures to prevent the non-compliance from occurring again; 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Return the plan of correction within 10 calendar days of receipt. If you have any questions, contact the licensing inspector at (540) 332-2330 or email rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-C
Complaint related:	Yes
Description:	Based upon review of residents' records, the facility failed to ensure medications are administered not earlier than one hour before and not later than one hour after the facility's standard dosing schedule. EVIDENCE: The late medication report consisting of 153 pages, for 05/01/19 through 05/21/19 indicates medications are consistently administered later than one hour after the facility's standard dosing schedule.
Plan of Correction:	Resident Wellness Directors (RWD?s) will ensure that medications are administered not earlier than one hour before and not later than one hour after the facility?s standard dosing schedule. RWD?s have adjusted facility?s standard dosing schedule and will provide routine oversight to ensure compliance. RWD?s have retrained all Registered Medication Aides on facility?s medication management policy. RWD?s will be installing a software that will enable documentation of medication administration to be completed in a timely manner via facilities electronic medication administration records (EMAR?s) even when there is an interruption in internet services.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based upon review of records, the facility failed to ensure medications are administered in accordance with the physician'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: The missed medication report for 05/01/19 through 05/20/2019 indicates the following: 1) Resident A missed 9:00am medications on 05/10/19 and 7:00pm scheduled medication on 05/20/19. 2) Resident B missed 6:00am medication on 05/07/19, 05/12/19, 05/13/19, 05/14/19 and 05/16/19. 3) Resident C missed 6:00am medication on 05/16/19. 4) Resident D missed 6:00am blood glucose check on 05/10/19. 5) Resident E missed 10:00pm medication on 05/04/19, 05/07/19, 05/08/19, and 2:00pm medications on 05/08/19. 6) Resident G missed 6:00am medication on 05/03/19 and 05/04/19. 7) Resident H missed 4:00am medication on 05/04/19 and 6:00pm medication on 05/06/19. 8) Residents I through O missed 6:00am medications on 05/04/19. 9) Resident P missed 2:00pm medication on 05/08/19. 10) Resident Q missed 9:00pm medication on 05/08/19.
Plan of Correction:	Resident Wellness Directors (RWD?s) will ensure that medications are administered in accordance with the physician?s instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. RWD?s have adjusted facility?s standard dosing schedule and will provide routine oversight to ensure compliance. RWD?s have retained all Registered Medication Aides on facility?s medication management policy. RWD?s will be installing a software that will enable documentation of medication administration to be completed in a timely manner via facilities electronic medication administration records (EMAR?s) even when there is an interruption in internet services.