VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Cardinal House
1182 Eastside Highway
Waynesboro, VA 22980
(540) 943-1470

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Feb. 6, 2020

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 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

*Consider requesting "PRN" status for medications physicians do not want to discontinue; * Include response to O2 levels when low on the medication administration records (MAR); *Remind/in-service staff to look at the order as well as medication container and consistently apply "order change" stickers to medication as applicable; *Continue to seek clarification from physicians related to parameters for lantus; and *Health inspection is due prior to renewal of license. Census: 34 Two Inspectors 8:15 am-4:30 pm

Comments:

The information contained in this renewal inspection report will be reviewed by the licensing administrator. The facility will be notified by mail regarding their renewal status. The facility had one violation during this unannounced renewal inspection process. It was in the area of medication administration. Details can be found in the violation portion of this report. The facility was clean and odor free. Physical plant updates are on going and individuals are included in the process picking color schemes and providing art work for the walls.Individuals interviewed noted they were happy to be at the facility and appreciated all the help they received. Activities are very popular at the facility including off site trips. The facility will be making adjustments to their activities program to accommodate those individuals who used to attend a local mental health run clubhouse program. Resident and staff files reviewed were complete and organized. Staff training exceeded the standard requirement. Outside inspections were current although the health inspection will need to be completed prior to the license expiration in March. Related drills were complete and met standard requirements. The facility currently maintains a three year license and there have been no complaints during that licensure period. Thank you to individuals and staff for your cooperation during this unannounced renewal inspection. Should you have additional comments or concerns please call (540)332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-680-D
Description:	Review of sample of medication administration records for the month of January and first part of February indicated that two individuals who receive insulin based on a sliding scale were not consistently receiving it from the most current physician's order. No ill effects had been noted for the individuals concerned.
Plan of Correction:	This was corrected prior to the completion of the inspection. It was determined that some staff were continuing to administer as per the pharmacy label as opposed to using the new order. There is also an issue that when orders are replaced the old order remains on the MAR and appear when the prescription number is coded in. The old order was dropped for the February MARS and a correct label was on the newly delivered insulin. In the future, "order change" labels will be placed on medication immediately when orders are changed by the person processing the change. Staff will also be receiving counseling and additional training immediately related to medication administration and responses to changes in medication orders. The administrative staff assume responsibility for future compliance.