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: June 18, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 32.1 Reported by persons other than physicians

Comments:

This inspection was completed as a follow-up to previous issues of medication mismanagement. The facility is on a provisional license and has been required to submit an Intensive Plan of Correction. There were four violations during this inspection. Details of non-compliance can be viewed in the violation notice section of this report. 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. The plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). If you have any questions, please contact the licensing inspector at (540) 332-2330 or email rhonda.whitmer@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based upon documentation, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1) Communication and documentation from home health on 06/12 /2019 indicates resident N has a stage II and stage III wound. 2) Documentation indicates resident N has the following orders effective 10/18/2018: a. Optifoam non-adhesive 4x4-Apply 1 patch over coccyx area once a week b. Wound Care: cleanse skin tear to right leg with wound cleanser and apply a small piece of Xeroform gauze. Cover with non-adhering dressing and secure with Kling once a week. 3) Previous reports, documentation and communication submitted to licensing included staging and measurements of open areas. The last reports submitted to licensing indicates open areas healed on 06/22/18 and and 07/25/2018.
Plan of Correction:	The Resident Wellness Directors or designee will ensure that regional licensing office is notified of all incidents that that have negatively affected or threatened the life, health, safety or welfare of any resident within 24 hours. The Resident Wellness Director or Designee will ensure that written report will be sent to licensing office within seven days to ensure compliance. Executive Director will provide daily oversight to ensure compliance.
Standard #:	22VAC40-73-450-C
Description:	Based upon review of residents' records, the facility failed to ensure all required information is included on the Individualized Service Plan (ISP). EVIDENCE: 1) The Uniform Assessment Instrument (UAI) for resident N indicates mechanical and physical assistance is required with bathing. The ISP does not identify mechanical supports needed. 2) The UAI for resident N indicates mechanical and physical assistance is required with transferring. The ISP does not identify mechanical supports needed. 3) The UAI indicates supervision is needed eating. Hospice note dated 05/29/2019 indicates resident needs to be fed due to not being able to hold utensils. 4) Hospice note dated 05/29/2019 indicates resident N is oxygen dependent. This is not indicated on the ISP. 5) The ISP is not signed by the resident or legal representative.
Plan of Correction:	Resident Wellness Directors with the support of Resident Care Coordinator and/or Memory Care Coordinator will ensure that all assessed needs of residents are included in the Individualized Service Plan (ISP). A comprehensive ISP will be completed within 30 days after admission and will include the following: ? Description of identified needs and date identified based upon the UAI, admission physical examination, interview with resident, fall risk rating, if appropriate; assessment of psychological, behavioral, and emotional functioning, and if appropriate, other sources. ? A written description of what services will be provided to address identified needs, and if applicable, other services, and who will provide them. ? When and where the services will be provided. ? The expected outcome and time frame for expected outcome. ? Date outcome achieved. An audit of all ISP?s will be completed to ensure compliance. ISP?s will be update accordingly to ensure compliance. Executive Director will provide oversight to ensure compliance. Immediately and ongoing Immediately and ongoing 07/25/19 Immediately and ongoing
Standard #:	22VAC40-73-680-C
Description:	Based upon review of the medication report from 05/21/2019 through 06/05/2019, 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: 1) The facility medication administration report indicates medications for residents A, B, C, D, E, F, G, H, and I were administered late on 05/21/2019. Documentation indicates "nurse to adjust med times." 2) The facility medication administration report indicates resident L's Oxycodone was late on 05/23/2019 at 5:00am. Documentation indicates "assisting with paperwork." 3) The facility medication administration report indicates resident M's blood glucose monitoring and Glimepiride were late on 05/30/2019 at 7:00am. Documentation indicates "night shift." There is no documentation indicating night shift completed.
Plan of Correction:	Resident Wellness Directors or designee 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. Resident Wellness Directors have adjusted facility?s standard dosing schedule and will provide frequent/routine oversight to ensure compliance. Resident Wellness Directors will retrain all Registered Medication Aides on facility?s medication management policy. Resident Wellness Directors 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 even when there is an interruption in internet services
Standard #:	22VAC40-73-680-C
Description:	Based upon review of the medication report from 05/21/2019 through 06/05/2019, 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: 1) The facility medication administration report indicates medications for residents A, B, C, D, E, F, G, H, and I were administered late on 05/21/2019. Documentation indicates "nurse to adjust med times." 2) The facility medication administration report indicates resident L's Oxycodone was late on 05/23/2019 at 5:00am. Documentation indicates "assisting with paperwork." 3) The facility medication administration report indicates resident M's blood glucose monitoring and Glimepiride were late on 05/30/2019 at 7:00am. Documentation indicates "night shift." There is no documentation indicating night shift completed.
Plan of Correction:	Resident Wellness Directors 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. Resident Wellness Directors have adjusted facility?s standard dosing schedule and will provide frequent/routine oversight to ensure compliance. Resident Wellness Directors will retrain all Registered Medication Aides on facility?s medication management policy. Resident Wellness Directors 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 even when there is an interruption in internet services.
Standard #:	22VAC40-73-680-D
Description:	Based upon documentation, 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: 1) The medication report from 05/21/2019 through 06/05/2019 indicates resident C did not received scheduled Metronidazole on 05/21/2019 at 2:00pm. 2) Resident N has the following order effective 10/15/2018: Cleanse skin tear to right leg with wound cleanser. Apply a small piece of Xeroform guaze. Cover with non-adhering dressing and secure with Kling once a week. a. Documentation in the electronic medication administration record indicates this was not completed on 06/05/2019 and on 06/12/2019 as home health agency completes. b. At time of documentation, resident N was not receiving services from named agency. c. Documentation from home health agency who started care on 06/12/2019 indicates the dressing on this area is dated 05/31/2019. d. Documentation from home health agency indicates wound measurements and completion of wound care on this area 06/12/2019. e. A handwritten medication administration record submitted from the facility on 06/19/2019 indicates dressing on this area was changed on 06/10/2019. No start date is indicated on the handwritten order for skin tear care. 3) Resident N has the following order: Carbidopa-Levodopa 25-250-Take 1 tablet by mouth three times a day for Parkinson's disease. Medication is scheduled for 6:00am, 11:00am and 5:00pm. a. Documentation in the electronic medication administration record indicates medication was held on 05/11/2019 at 11:00am due to " held for she just received morning dose." 4) The medication report from 05/21/2019 through 06/05/2019 indicates resident K did not received scheduled Sodium Chloride on 05/23/2019 at 6:00am.
Plan of Correction:	Not available online. Contact Inspector for more information.