VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Crozet Campus
1220 Crozet Avenue
Crozet, VA 22932
(540) 810-6200

Current Inspector: Tamara Watkins (804) 662-7422

Inspection Date: Aug. 27, 2019

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

An unannounced focused inspection was conducted on 8/27/19 by 3 licensing inspectors from approximately 10:50 a.m. - 4:20 p.m. to follow up on a complaint reported to the department. The current census at the facility is 70. During the inspection, 1 resident record was reviewed, facility documentation was reviewed, medication administration records and physician orders were reviewed and staff interviews were conducted. The allegations of the complaint were founded. An exit meeting was held with the administrator. A violation was cited during this inspection. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector within 10 days. 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: 1) steps to correct the non-compliance 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 contact me by e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.

Violations:

Standard #:	22VAC40-73-680-I
Complaint related:	No
Description:	Based on the review of resident record, facility documentation and interviews with staff, the facility failed to ensure that prescribed medication was transcribed onto the medication administration record (MAR). Evidence: 1) Resident #1 was admitted to the facility (admission date 6/7/19) with prescription for Selexipag 1400 MCG to be administered two times a day for pulmonary hypertension. This medication was not administered to resident #1 until 7/2/19 because it was not transcribed onto the MAR upon resident #1 admission to the facility. 3) During the time of inspection, the resident care coordinator confirmed that the Selexipag 1400 MCG was not administered to resident #1 until 7/2/19. The resident care coordinator also stated that staff #1 (medication aide) was responsible for transcribing medications to the MAR, however staff #1 forgot to add the medication to the MAR. The resident coordinator also confirmed that the medication omission was discovered when resident #1 daughter visited the facility to inquire about prescription refills, and at that time discovered the medication was not listed on the MAR. 3) The inspector reviewed the initial history and physical examination report received upon admission of resident #1, which also confirmed that Selexipag 1400 MCG was listed as a prescribed medication for the resident.
Plan of Correction:	Upon admission, Administrator, Director of Nursing (DON) and Assistant Resident Care Coordinator (ARCC) will review history and physical of new residents and match orders to their medication administration records (MAR). MARs and resident records will be audited monthly to ensure corrections.