VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Accordius Health at Nans AL LLC
200 West Constance Road
Suffolk, VA 23434
(757) 539-8744

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 19, 2020 and May 20, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 The Criminal History Record Report

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 05-19-2020 and concluded on 05-20-2020. The ALF Director was contacted by telephone to initiate the inspection. The ALF Director reported that the current census was 14. The inspector emailed the ALF Director and Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, criminal background checks and sworn disclosures of newly hired staff, staff schedules, fire drills, fire and health inspection reports, dietary oversight, and healthcare oversight. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview, the facility failed to ensure the physician's oral orders are reviewed and signed by a physician within 14 days. Evidence: 1. Staff #1 provided a copy of resident #2?s telephone order dated 04-17-2020 which documented ?Hold weekly weights for COVID-19.? The order did not contain the physician?s signature as of the inspection date (05/19/2020) indicating the order had been reviewed and signed within 14 days. 2. During interview on 05-19-2020, staff #1 acknowledged resident #2?s telephone order had not been reviewed and signed by the physician within 14 days.
Plan of Correction:	1. Facility failed to ensure that resident #2?s physician oral orders are reviewed and signed by physician within 14 days. 2. All staff in-serviced on making sure physician?s orders are reviewed and signed within 14 days of obtaining order(s). 3. Program Director or designee will perform audit on resident?s physician orders weekly x 4, monthly x 4, quarterly then annually starting 06/25/2021 to ensure compliance. 4. All residents? physician orders were reviewed for compliance. Physician order audit was initiated and will be completed monthly by the Program Director or her designee to ensure compliance. 5. Program Director will monitor all staff to maintain compliance.
Standard #:	22VAC40-73-680-D
Description:	Based on record review and interview, the facility failed to ensure medications are administered in accordance with the physician's instructions and are consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. Evidence: 1. Resident #1?s current signed physician?s orders (with a print date of 04-20-2020) documented ?Insulin Lispro Kwikpen-100U- inject sq per sliding scale? if 300-349 inject 12 units; if 350-399 inject 14 units?? 2. Resident #1?s May 2020 Medication Administration Record (MAR) documented the resident?s blood sugar was ?346? on 05-08-2020 during the 11:00 AM medication administration. On the MAR, staff documented ?14 units of Lispro? was administered on 05-08-2020. The physician?s instructions indicated 12 units of Lispro Kwikpen insulin for a blood sugar reading of 346. 3. During interview, staff #1 and staff #2 acknowledged resident #1?s medication was not administered in accordance with the physician?s instructions.
Plan of Correction:	1. Resident #1?s Lispro were not given according to Physician?s orders. Resident #1?s medications were not administered in accordance with Physician?s orders. 2. All staff were in-serviced on following Physician?s orders for proper Medication administration. 3. Program Director or designee will perform random medication pass weekly x 4, monthly x 4, quarterly then annually starting 06/25/2021 to ensure compliance. 4. Program Director will monitor all staff for accuracy to maintain compliance.
Standard #:	22VAC40-73-680-H
Description:	Based on record review and interview, the facility failed to documented on a medication administration record (MAR) all medications administered to residents at the time of administration. Evidence: 1. Resident #1?s signed physician?s orders (with a print date of 04-20-2020) documented ?Bydureon injection 2/0.85ML- Inject 2mg subcutaneously weekly for DM II.? 2. On 05-19-2020, staff #2 provided a copy of resident #1?s May 2020 MAR. Staff #3?s (Registered Medication Aid) initials were documented indicating the Bydureon injection 2/0.85ML was administered to the resident on 05-06-2020 and 05-13-2020. 3. During interview on 05-19-2020, staff #1 stated she administered the Bydueron injection to the resident on 05-06-2020 and 05-13-2020, however did not initial the MAR at the time the medication was administered. 4. On 05-20-2020, staff #1 provided a signed letter dated 05-20-2020 which documented ?I, staff #1, LPN administered Bydureon on May 6, 13, and 20th. The RMA staff #3 was there to witness it was given.? 5. Resident #1?s signed physician?s orders (with a print date of 04-20-2020) documented ?Mag Oxide 400mg- one tablet by mouth once daily; and Pot Chloride 10 MEQ- one tablet by mouth twice daily.? The resident also had a signed physician?s telephone order dated 04-17-2020 to documented ?Hold Potassium Chloride 10 meq for 30 days, hold Magnesium Oxide 400mg for 30 days.? 6. On 05-19-2020, staff #1 provided a copy of resident #1?s May 2020 MAR. The MAR did not include staff?s initials documenting the Potassium Chloride 10meq and Magnesium Oxide 400mg was administered to the resident on 05-18-2020 and 05-19-2020. 7. On 05-20-2020, staff #1 re-sent a copy of resident #1?s May 2020 MAR. The MAR was initialed by staff documenting the Potassium Chloride 10meq and Magnesium Oxide 400mg was administered to the resident on 05-18-2020 and 05-19-2020. 8. During interview on 05-20-2020, staff #1 acknowledged staff did not document on resident #1?s MAR all medications administered to the resident at the time of administration.
Plan of Correction:	1. Resident #1?s medications was not documented on medication administration record (MAR) at the time of administration. 2. All staff were in-serviced on documenting medication(s) on medication administration record (MAR) at the time medication(s) administered. 3. The Program Director or designee will audit all resident?s medication administration record MAR to ensure medication(s) are documented on medication administration record (MAR) at the time of administration. 4. The Program Director or designee will audit medication administration record MAR weekly to ensure compliance. Audit will be conducted weekly x 6 months, then monthly starting 06/25/2021 to ensure compliance.
Standard #:	22VAC40-73-700-1
Description:	Based on resident record review and staff interview, the facility failed to ensure the valid physician's or other prescriber's oxygen order included all required information. Evidence: 1. Staff #1 provided a copy of resident #2?s physician orders dated 04-15-2019, which documented ?2 liters of oxygen at rest and with activity.? The order did not include the oxygen source or delivery device. 2. Staff #1 acknowledged resident #2?s physician?s order did not include the oxygen source and delivery device.
Plan of Correction:	1. Resident #2 oxygen physician?s order did not include all required information. 2. All staff in-serviced on making sure physician?s order(s) includes all required information. 3. Program Director or designee will perform audit on resident?s physician orders weekly x 4, monthly x 4, quarterly then annually starting 06/25/2021 to ensure compliance. 4. All residents? physician orders were reviewed for compliance. Physician order audit was initiated and will be completed monthly by the Program Director or her designee to ensure compliance. 5. Program Director will monitor all staff to maintain compliance.
Standard #:	22VAC40-90-50-B
Description:	Based on record review and interview, each criminal history record report should be verified by the operator of the facility by matching the name to establish that all information pertaining to the individual cleared through the Central Criminal Records Exchange is exactly the same as another form of identification such as a driver's license. If any of the information does not match, a new criminal history record request must be submitted to the Central Criminal Records Exchange with correct information. Evidence: 1. Staff #1 provided a list of newly hired staff with the staff?s date of hire, which included staff #3 (date of hire 04-02-2020). 2. Staff #3?s criminal history record report dated 03-27-2020 did not include the staff?s entire first name, as shown on the staff?s driver?s license. 3. Staff #1 did not provide additional documentation of a new criminal history record with staff #3?s correct information, as of the date of inspection on 05-19-2020 and 05-20-2020. 4. Staff #1 acknowledged the criminal history record report did not match staff #3?s name.
Plan of Correction:	1. Facility failed to ensure that staff #3?s criminal history record report include the staff?s entire first name as shown on the driver?s license. 2. All staff files will be audited to ensure that their criminal history record report include staff?s entire first name as shown on their driver?s licenses. 3. Facility Program Director was in-serviced to ensure that all staff criminal history record report include staff?s entire first name as shown on their driver?s licenses. 4. Program Director or the designee will audit monthly x 6 months then yearly, all staff personnel file to ensure compliance.