VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Journeys Crossing
102 N. Stuart Avenue
Elkton, VA 22827
(540) 298-0054

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: June 10, 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 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

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 monitoring inspection was initiated on 06/10/2020 and concluded on 06/12/2020. Mandy Coffman, the administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 28. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, criminal history reports, outside inspections and drills submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based upon review of residents' records, the facility failed to ensure all assessed needs are identified on the Individualized Service Plan (ISP). EVIDENCE: 1) The UAI for resident A indicates Abusive/Aggressive /Disruptive behavior ("will ring for assistance then claim not ringing call bell.") The ISP indicates there are no current behaviors. a. The UAI indicates disoriented to some spheres some of the time. The ISP indicates "poor short term memory, disoriented to real time and abilities; staff to report any issues." There are no interventions identified on the ISP. 2) The UAI for resident C indicates disoriented to some spheres some of the time. The ISP indicates "poor short term memory; staff to re-orient to highest abilities." There are no interventions identified on the ISP. a. The UAI indicates resident requires physical and mechanical assistance with transferring. The ISP indicates resident is able to transfer self from place to place using walker or wheelchair. b. Hospice services provided are not identified on the ISP. c. The ISP indicates resident "doesn't understand how or when to use call bell; staff to round and document. Frequency of rounds are not indicated on the ISP. 3) The UAI for resident D indicates disoriented to some spheres some of the time. The ISP indicates "poor short term memory; staff to report issues." There are no interventions identified on the ISP. a. The UAI indicates Abusive/Aggressive/Disruptive behavior. There are no interventions identified on the ISP.
Plan of Correction:	Items listed in inspection have already been corrected 6/16/2020. Facility administrator will ?double check? UAI and ISP for all residents, including new admissions, change of condition or special considerations, completed by administrator or designee for correctness and completion.
Standard #:	22VAC40-73-640-A
Description:	Based upon review of the medication management plan, the facility failed to implement and monitor procedures within the written plan for medication administration. EVIDENCE: 1) The facility medication management plan indicates a review of the Electronic Medication Administration Record (EMAR) shall be performed bi-monthly to ensure accurate and complete documentation (to include timely documentation of PRN medications). 2) The medication management plan indicates for changed orders, the medication aide will get the order and verify that the order and EMAR match and this should be done within 24 hours of receipt. IF the medication aide agrees, the order will be merged, the date and initials wrote on order and the order will be placed in the filing bin. If the order and the EMAR does not match, the medication aide will contact the pharmacy for clarification. If the EMAR and order still do not match, contact the nursing director and the medication aide will communicate change at the end of shift reporting. 3) The medication management plan indicates if there are discrepancies and concerns, the medication aide will call the pharmacy and communicate the problem/concern. 4) Please refer to violations 22VAC-40-73-680D and 22VAC-40-73-680I in the violation notice section of this report.
Plan of Correction:	The facility medication administration record (MAR) will be reviewed for new orders, changed orders and vital variances by the Administrator every business day for 4 weeks, then weekly for 4 weeks, then bi-weekly for 4 weeks, then bi-monthly per medication administration plan to ensure accurate and complete documentation to include PRN medications. Dates to be completed are 07/17/20, 08/14/20 and 09/09/20.
Standard #:	22VAC40-73-680-D
Description:	Based upon review of residents' records, the facility failed to ensure medications are administered in accordance with the physician's instructions and consistent with the standards of practice outlined in the current registered medication aide curriculum approved by the Virginia Board of Nursing. EVIDENCE: 1) Resident A has the following order: Take O2 sats twice a day. Report if greater than 100; O2 less than 90%, on up to 3 liters per minute by nasal cannula. a. The MAR for resident A indicates the following order: Oxygen via nasal cannula at 2 liters per minute continuously by way of portable and/or concentrator for COPD or shortness of breath. b. There is no documentation of O2 saturation being recorded in the MAR. 2) Resident B has the following order: Take blood pressure once daily; give Clonidine 0.1mg tablet if BP is greater than 165. a. Documentation in the MAR indicates resident's blood pressure as 170/98 on 05/05/20. The MAR indicates Clonidine was not administered. b. Documentation in the MAR indicates resident's blood pressure as 170/90 on 05/26/20. The MAR indicates Clonidine was not administered.
Plan of Correction:	Facility administrator to re-educate all medication aides on the process of new medication orders, and complete documentation to administer medications based on vital signs and follow up. Facility administrator to check for compliance every business day for 4 weeks, then weekly for 4 weeks, then bi-weekly for 4 weeks, then bi-monthly per medication administration plan to ensure accuracy and correct administration parameters. Dates to be completed are 07/17/20, 08/14/20 and 09/9/20.
Standard #:	22VAC40-73-680-I
Description:	Based upon review of resident's records, the facility failed to ensure all required information is documented in the electronic MAR. EVIDENCE: 1) The Medication Administration Record (MAR) for resident A indicates Acetaminophen was administered on 06/04/20. Documented results "resident states it did not help." There is no documentation of follow-up. 2) The Medication Administration Record (MAR) for resident B indicates Clonidine was administered on 05/14/20, 05/20/20, 06/03/20 and 06/04/20 due to BP being over 165. Documented results on 05/14/20, 06/03/20 and 06/04/20 indicate "bp came down." There is no recording of blood pressure. a. Documented results on 05/20/20 " resident sitting in chair relaxing." There is no recording of blood pressure.
Plan of Correction:	Facility administrator to educate all medication aides on complete documentation to PRN administration and follow up. Facility administrator to check PRN orders and follow up for correctness.