VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tribute at The Glen
4151 Old Bridge Road
Woodbridge, VA 22192
(571) 402-1870

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: July 19, 2019 and July 23, 2019

Complaint Related: No

Areas Reviewed:

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

Comments:

Date of Inspection: July 19 and 23, 2019 9am to 330pm Type of Inspection: Monitoring Inspection conducted on self-reported incident related to medication management issues. Census 95 If you have any questions or email changes, please do not hesitate to contact me at ken.koontz@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Number of records reviewed and interviews conducted-3 resident records, 9 employee records, 11 interviews. This non-mandated monitoring inspection was to investigate a self-reported incident. Not all health and safety standards were reviewed. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violation(s) for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please have the corrected action completed by the COB 8/27/2019. The facility has provided comments on each violations. The comments are maintained in the facility record, and are available upon request.

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on chart review and interviews, it was determined the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures. Evidence: The licensee failed to provide supervisory oversight that allowed for staff to administer medication, including narcotics, and perform narcotic counts for a six month period, which were not qualified in Virginia to administer medications. Staff F was appointed as acting administrator on March 18, 2019. Staff F no longer meets the requirements to be administrator, since 150 days has passed, and she has not applied to be a licensed assisted living facility administrator.
Plan of Correction:	1. Licensee will have a licensed administrator or administrator-intraining. a. Staff E applied to be a licensed assisted living facility administrator in July 2019. Acceptance as an administrator-in-training should occur by 8/30/19.
Standard #:	22VAC40-73-70-A
Description:	Based on chart review and interviews, it was determined 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: A medication error was discovered on July 8, 2019 by Hospice Agency A. Nurse of Hospice Agency A documented a discussion with the charge nurse, and an email to the Administrator of the medication error. The administrator verified the receipt of the email. The LI was notified of the event on July 12, 2019, via email. The standard requires notification within 24 hours.
Plan of Correction:	1. Update Thrive Policy - Medication Management Program Guidelines ? Virginia a. Section: Procedures, paragraph. 7, add VDSS to list of reporting members. ?Report any alleged major incidents that negatively affect or threaten the life, health, safety or welfare of any resident, including major medication errors to VDSS. Medication errors will be immediately reported to the attending physician, CommunityPresident, Vice President of Resident Experience, VDSS, and family.? 2. Amend agreements between hospice agencies and Tribute at The Glen (TATG). a. Medication errors will be reported immediately via verbal communication to VP of Resident Experience (VPRX) and/or Administrator upon discovery. b. Reason: In this case, communication to VDSS was delayed because critical, time-sensitive information was sent via email. Therefore, the VPRX and/or Administrator was unable to preserve evidence and quickly ascertain the facts surrounding the medication error. 3. New TATG Internal Guidance: a. Inform VA inspector whenever there is a major incident that negatively affects or threatens the life, health, safety or welfare of any resident, including alleged or confirmed medication errors within 24 hours. o The first notifier would be the President/Administrator. o The second back-up would be the VPRX (cc the President/Administrator). o The third notifier would be the CBD (cc the Administrator and VPRX). b. After initial 24hr notification, update VDSS within 48hrs of any alleged medication error that are confirmed upon further investigation. Monitor for the next 12 months for any other medication errors and ensure that compliance with the new TATG Policy Guideline is performed
Standard #:	22VAC40-73-150-C
Description:	Based on chart review and interviews, it was determined the administrator failed to ensure that care was provided to residents in a manner that protects their health, safety, and well-being, maintaining compliance with applicable laws and regulations and the supervision of staff. Evidence: Staff E and F transferred to the facility in March, 2019, as the new administrative team. Staff B was hired on May 5, 2019, and administered medications, administered schedule 2 medications and performed the shift count for schedule 2 medications. Staff C, employed in January, 2019, administered medications, administered schedule 2 medications and performed the shift count for schedule 2 medications, also. Both were not registered in Virginia to administer medications. Resident A?s narcotic log had documentation that Staff B and C had over 6ml extra morphine used between July 6 at 9am until July 7 at 8pm. Staff B and C have documentation of administering medication on July 19, 20 and 21, after administration had verified these two staff persons did not have the qualifications to administer medications.
Plan of Correction:	1. Immediate 100% audit of all care team members for proper licensure as nurses, medication technicians and CNAs. a. A total of 92/94 team members had valid credentials for their respective positions (i.e. VA State, occupation, expiration date, and status). b. Staff B and Staff C did not have valid Virginia medication licenses for their respective positions as medication technicians. Staff B had a valid Maryland medication technician license and had applied and paid for a Virginia license prior to employment. Staff C had a training certificate for medication technician but did not have the training hours and had not started the process for Virginia licensure. Staff B and Staff C are no longer employed by TATG. 2. Perform a 100% audit for proper licensure every month for the next 6 months to ensure compliance with VA State regulations. 3. TATG selection/hiring process for all care team members will include the following: a. Includes verification of proper licensure during the pre-selection process (i.e. no provisional licenses). b. VP of Resident Experience or designated licensed nurse will verify proper licensure during interview process. c. Community Business Director (CBD) will verify proper licensure after interview by VPRX or designated licensed nurse as part of the preselection/hire process. 4. Tracking for care team licensure will be completed the 1st of each month. a. CBD is responsible for monthly tracking of all care team member licensures. b. CBD will give notice to VPRX or designated licensed nurse of care team members that have license expiration dates within 60 days. c. VPRX or designated licensed nurse will remove from the work schedule any care team member whose licensure expires without renewal. 5. Logging of all liquid medication dosages will be done in milliliters (ml) and not milligrams (mg). a. The .25ml dosage is the same is 5mg for liquid medication. The narcotics log indicated correct dosages of medication in ml or mg, but had math 2. 7/23/19 3. 8/1/19errors for the remaining amounts of narcotics that is indicated in ml.
Standard #:	22VAC40-73-640-A
Description:	Based on chart review and interviews, it was determined the facility failed to keep current, and implement a written plan for medication management. Evidence: The medication management policy describes the requirement for a nurse taking a telephone order for medication, but is not specific of how this information is relayed to the pharmacy, or documented on the MAR. In the medication error for Resident A, Staff A, a LPN, changed the MAR to administer the morphine every 2 hours. The verbal order was for the morphine to be administered every 12 hours. No documentation was provided to verify the pharmacy was notified of the verbal order as required by the medication plan. The narcotic administration For Resident A documented the correct morphine dosage (0.25ml or 5mg) administered, but documented a different amount of medication was remaining. A review of the narcotic log found the amount of morphine remaining was documented incorrectly by the same two non-qualified staff 9 times over two days, July 6 and 7, 2019. This resulted in over 6ml (24 dosages) of morphine unaccounted. The daily narcotic count was completed by Staff C and D. The medication discrepancy was not reported as required by the facility policy. Staff C is not qualified to pass medication This loss of a schedule 2 medication was not reported by the medication aides or nurses, or investigated, as required by the administration policy. The vial of morphine was not destroyed in accordance with the facility policy. The pharmacy consultant or Health and Wellness were not involved in the process.
Plan of Correction:	1. Update Thrive Policy - Medication Management Program Guidelines ? Virginia a. Section: Physicians Orders/Prescriptions. Update to specify how a telephone order is relayed to the pharmacy and documented on the MAR. b. Monitor monthly for 6 months to ensure compliance with updated Medication Management Program Guidelines. 2. New TATG Internal Guidance: a. A licensed nurse will document in progress notes and/or stamp ?Faxed? on telephone order to verify that the pharmacy was notified b. Night shift licensed nurse (11pm7am) will perform a second review and verification all new physician signed orders for the day and ensure they have been transcribed accurately. c. Controlled-Substance Log Book (narcotic book) will be audited weekly by licensed nurse to ensure accuracy and compliance with Medication Management Program Guidelines. i. Assisted Living: AL licensed nurse. ii. Memory Care: Audited by Memory Care Coordinator or licensed nurse. 3. Narcotic will be destroyed as per our current medication destruction policy (by a licensed nurse and the Vice President of Resident Experience).
Standard #:	22VAC40-73-650-A
Description:	Based on chart review and interviews, it was determined the facility failed to ensure that no medication be started, changed, or discontinued by the facility without a valid order from a physician or other prescriber Evidence: A medication error began on 7/7/2019, where the hospice nurse obtained a verbal order to change the administration of 5mg of morphine from every 8 hours to every 12 hours. The hospice nurse documented this was at the request of the family as they felt their mother was becoming more somnolent (sleepy). A facility nurse, Staff A, documented the medication change incorrectly to administer every 2 hours. The medication was administered every 2 hours for approximately 24 hours. The error was found by the hospice nurse upon her return to the facility on Monday, 7/8/2019. The facility nurse was then notified by the hospice nurse to notify the physician and pharmacy of the error. The resident died prior to any changes or interventions.
Plan of Correction:	1. New TATG Internal Guidance: a. All telephone orders written by a hospice nurse will be verified by TATG licensed nurse. TATG licensed nurse will document verified and/or noted on the order. Order will then be faxed to pharmacy then transcribed into the electronic medical record. b. Hospice nurse will take a copy of the written order and return signed order by their physician within 14 days. c. TATG licensed nurse working the night shift (11pm-7am) will perform a second review and verification of all new physician signed orders for the day and ensure they have been transcribed accurately. 2. Monitor team, including hospice nurse for 6 months to ensure compliance with updated policy.
Standard #:	22VAC40-73-670-1
Description:	Based on chart review, it was determined Staff B and C were administering drugs without being a registered medication aide Evidence: Staff B, hired May 3, 2019 and Staff C, hired January 3, 2019, were administering medications without being registered in Virginia. After all parties involved were aware on July 19, 2019 that Staff B and C did not have the qualifications to administer medications, Staff B and C were allowed to continue to administer medications, including narcotics.
Plan of Correction:	1. 100% audit of all care team members for proper licensure as nurses, medication technicians and CNAs. a. A total of 92/94 team members had valid credentials for their respective positions (i.e. VA State, occupation, expiration date, and status). b. Staff B and Staff C did not have valid Virginia medication licenses for their respective positions as medication technicians. Staff B had a valid Maryland medication technician license and had applied and paid for a Virginia license prior to employment. Staff C had a training certificate for medication technician but did not have the training hours and had not started the process for Virginia licensure. Staff B and Staff C are no longer employed by TATG. 2. Perform a 100% audit every month for the next 6 months to ensure compliance with VA State regulations. 3. TATG selection/hiring process for all care team members: a. Includes verification of proper licensure during the pre-selection process (i.e. no provisional licenses). b. VP of Resident Experience or designated licensed nurse will verify proper licensure during interview process. c. Community Business Director (CBD) will verify proper licensure after interview by VPRX or designated licensed nurse as part of the preselection/hire process. 4. Tracking for care team licensure will be completed the 1st of each month. a. CBD is responsible for monthly tracking of all care team member licensures. b. CBD will give notice to VPRX or designated licensed nurse of care team members that have license expiration dates within 60 days. c. VPRX or designated licensed nurse will remove from the work schedule any care team member whose licensure expires without renewal