VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Highland House
3501 Longdale Furnace Road
Clifton forge, VA 24422
(540) 862-4271

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Oct. 17, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

On 10/17/2019 one inspector conducted a renewal study (10:20am to 4:45pm). 18 residents were in care. Six resident records and three staff records were fully reviewed, and additional records were partially reviewed. All staff hired since the prior inspection had records reviewed for background checks. A physical plant tour was done. A medication pass was observed. Staff and residents were interviewed. The administrator and LI had a discussion regarding how to document a uniform assessment instrument (UIA) if a resident needs help with taking most medications, but is able (and has orders) to self-administer some medications. There was a discussion regarding DNR forms. There was a discussion of methods of dealing with occasional odors that occur in the same part of the building. There was a discussion of updating the posted resident rights with the current Licensing Administrator name, and reviewing other posted documents for accuracy and current information. During the inspection and at the exit interview, the facility was given the opportunity to discuss the violations and to show that they were in compliance. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain the following: 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). If you have any questions, please contact your licensing inspector at 540-309-3043.

Violations:

Standard #:	22VAC40-73-260-C
Description:	Based on observation, the posted listing of staff with first aid and CPR was not updated with current information. EVIDENCE: 1. The posted listing did not have full information regarding current first aid and CPR cualifications for staff.
Plan of Correction:	1.) A visible list of all staff CPR/First Aid and their expiration dates was posted on 10/18/19. Updated staff tickler file with this information was printed and posted as well on 10/17/19.
Standard #:	22VAC40-73-380-A
Description:	Based on resident record review, the facility failed to obtain some required information on a new resident. EVIDENCE: 1. The personal and social date form for resident 1 was missing information regarding: legal representative, contact person, responsible party, life time career or role, allergies.
Plan of Correction:	1. The personal/social data sheet was updated and the facility will be using the VDSS model form going forward.
Standard #:	22VAC40-73-450-C
Description:	Based on resident record review, the facility failed to address some needs on comprehensive individualized service plans (ISP). EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 5, dated 5/8/2019, shows needs of mechanical help with supervision when climbing stairs. The ISP, dated 5/9/2018, does not address supervision. 2. The physical for resident 6, dated 8/22/2019, shows allergies to: Allegra, ace inhibiters, thiazides, PCN [penicillin], sulfa, estrogen, aspirin, Excedrin, Sudafed, triamcinolone, colchicine, piroxicam, clindamycin, and nitrofurantoin. The ISP, dated 9/30/2019, addresses multiple drug allergies but does not list the specific allergies.
Plan of Correction:	1.) The UAI for resident 5 was updated on 10/18/19 to reflect mechanical help only. The UAI and ISP now match. 2.) The ISP for resident 6 was updated on 10/18/19 to reflect each allergy in the box for allergies. The allergies were listed at the top of the ISP under resident?s name.
Standard #:	22VAC40-73-450-D
Description:	Based on resident record review, the facility failed to show specific services to be provided by hospice on an individualized service plan (ISP). EVIDENCE: 1. The ISP shows that resident 4 has hospice services. The ISP does not show what specific services are provided.
Plan of Correction:	1. The ISP for resident 4 was updated on 10/24/19 to more clearly outline what specific services hospice will be providing.
Standard #:	22VAC40-73-640-A
Description:	Based on observation and document review, the facility failed to fully address how to avoid the use of outdated medications in their medication management plan. EVIDENCE: 1. The medication cart had a Lantus SoloStar insulin pen for resident 6. This medication is good for 28 days after it is removed from refrigeration. The Lantus SoloStar pen did not have an open date or a discard date on it. 2. The medication cart had a Toujeo SoloStar insulin pen for resident 9. This medication is good for 42 days after it is removed from refrigeration. The Toujeo SoloStar pen did not have an open date or a discard date on it. 3. The facility?s medication management plan does not address how to handle medications that have shortened expiration dates, such as those listed in 1 and 2 above.
Plan of Correction:	1.) The undated Lantus was removed on 10/17/19 and a new Lantus was taken out and properly dated the next time of administration. All Registered Medication Aides trained again on properly dating insulin. 2.) The undated Toujeo SoloStar was removed on 10/17/19 and a new Toujeo Solo Star was taken out and properly dated the next time of administration. All Registered Medication Aides trained again on properly dating insulin. 3.) The Medication Management Plan was updated to reflect weekly medication cart audits.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review, the facility failed to have a complete order for oxygen for a resident. EVIDENCE: 1. The oxygen order for resident 5 does not identify the source(s) of the supplemental oxygen.
Plan of Correction:	1. Appropriate order for oxygen to contain the source of the oxygen was obtained on 10/24/19. Order was updated in MAR and in chart. All new admission orders will be monitored to ensure this information is complete.