VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Auburn Hill at Swift Creek
5800 Harbour Lane
Midlothian, VA 23112
(804) 456-4455

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: June 1, 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 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.

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 or Virginia. A monitoring inspection was initiated on 6/1/20 and concluded on 6/1/20. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 32. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records 3 staff records,staff schedules, criminal background checks, health and fire inspections,health care oversight, medication administration records,etc.submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Areas of non-compliance are identified in the Violation Notice. The facility has 10 calendar days from receipt of the inspection reports to complete a plan of correction, sign the inspection report and return them to the licensing office. A copy of the inspection reports shall be retained and posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS website within 15 calendar days, regardless of whether the plan or correction is completed. The plan of correction shall include the following: (1) Step(s) the facility will take to correct the violations cited; (2) Measures that will be put in place to prevent recurrence of each violation; (3) Person(s) responsible for implementation and monitoring of preventive measures; and (4) Date by which each violation will be corrected.

Violations:

Standard #:	22VAC40-73-310-H
Description:	Based on a review of resident records and supporting documentation the faciility admitted a resident with a care need or condition prohibited by this standard. Evidence: The admission physical examination form for resident #1 dated 2/10/20 checked a statement that the resident "requires continuous licensed nursing care".
Plan of Correction:	The Nurse Practitioner who provides services to resident #1 has provided documentation that resident #1 does not have a prohibited condition and remains appropriate for Assisted Living placement. No harm occurred as a result of this practice. The DHW or designee will audit admission History and Physicals for all residents for any addition clarification documentation needed. The ED or designee will education the DSM, DHW, and the DIMC on review of the history and physical form prior to an admission and that admission will not be afforded to residents with prohibited conditions. The ED or designee will monitor new admission paperwork for the next 4 weeks to ensure accuracy and identify any potential prohibited conditions documented. Additional education and corrections will be made as identified.
Standard #:	22VAC40-73-680-D
Description:	Based on a review of 5 resident MAR's the facility failed to administer medications in accordance with the physician's order. Evidence: 1. Resident #3 had a physician order dated 3/3/20 for Silodosin 4mg. The Medication Administration Record for the month of April, 2020 lists the medication (Silodosin) is effective 4/2/20 ending 5/21/20. A review of the MAR for 4-2 through 4-30- 2020 documents that Silodosin was not given because the medication was "not available"-"prior authorization needed".The Physician's Order was still in effect as it was not discontinued. 2. A physician order for resident #3 was in effect for 4/2/20 for Humalog Insulin VL-7510 Inject 3 times a day/ Before Meals for Diabetes Mellitus. Check Blood sugar before administering Hold if BS is Less than 90.The MAR documents that insulin was not given on 4/22, blood sugar 116; 4/23, blood sugar 103; 4/27, blood sugar 120; 4/28, blood sugar 128; 4/29, blood sugar 123. The reason for not given was listed as "outside of the parameters". It is unclear why the insulin was not administered as the blood sugar levels were over 90.
Plan of Correction:	1. Silodosin was discontinued. No harm occurred as a result of this practice. The DHW or designee will audit the last 30 days of any held medications and communicate with the physician as needed. The DHW or designee will educate the nursing team on the process of physician notification for held medications related to availability or insurance coverage issues. The DHW or designee will monitor the missed medication report weekly for 4 weeks. Any additional education or corrections will be made based on this monitoring. A daily review of held medications will continue as a part of the daily stand up meeting process. 2. Upon interview with the RMA who documented these dated entries on the MAR, she reported that the insulin was administered. She reports that she perceived parameters to mean the time frame that medications can be administered and that she had administered the insulin late. No harm occurred as a result of this practice. The DHW or designee will audit the current MAR for residents who receive insulin with blood sugar parameters. The DHW or designee will educate RMA and LPN team members how to read parameter orders and appropriate documentation. The DHW or designee will monitor the MAR?s of residents who receive insulin with blood sugar parameters weekly for 4 weeks. Any additional education or corrections will be made.