VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Commonwealth Senior Living at Radford
7486 Lee Highway
Radford, VA 24141
(540) 639-2411

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Sept. 1, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 09/01/2020 and concluded on 09/22/2020. A self-reported incident was received by the department regarding medications which had been stored improperly. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards of law, and violations were issued. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice. As a result of this inspection two violations are being cited. Please develop a plan of correction for each violation cited along with a date of correction and return a signed and dated copy back to the licensing office within 10 calendar days (10/02/2020) or receipt. If you have any questions please feel free to contact your licensing inspector at 276-608-1067. Thank you for your cooperation and assistance.

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on information provided during staff interviews and review of the medication management plan, the facility failed to implement their written medication management to include a plan for proper disposal of medication. EVIDENCE: 1. The medication disposal portion of the facility?s medication management plan was updated on 06/12/2019. This plan states that ?medication destruction shall be done on a regular basis. Medications should not be stockpiled waiting for destruction? and that ?discontinued medications will be returned to the pharmacy or destroyed within 72 hours of discontinuance?. 2. Staff #1 stated that the 70.5 Lorazepam 0.5 mg tablets, 24 Tramadol 50 mg tablets, 66 Clonazepam 0.5 mg tablets, one containers of liquid Morphine Sulfate 100 mg, 29.25 mL, once container of Morphine 20 mg, 28.75 mL and one container of liquid Lorazepam 2 mg, 30 mL were discovered in an administrative office in an unlocked and unsecured upright cabinet. These medications were for Resident #1 discharged 7/29/2020; Resident #2 discharged 07/31/2020; Resident #3 discharged 07/22/2020; Resident #4 discharged on 07/09/2020, and Resident #5 discharged 07/28/2020. All five residents have been discharged from the facility for a period greater than 72 hours when this report was received on 09/01/2020. 3. The medication management plan states that for the destruction and disposal of narcotic medications and non-narcotic medications the ?destruction must be witnessed by the Med Aide on duty or Resident Care director and another adult witness who is an employee of the community?. Narcotic medications and non-narcotic medications can be disposed of by either returning to the pharmacy or by placing in medical waste receptacles in accordance with the manufacturer?s instructions. 4. The medication management plan also states, ?The Resident Care Director and Med Aide will document destruction of the medication on the Medication Disposition Record (or other approved documentation system.) The destruction is documented by completing all items listed on the form, including the amount of medication destroyed and a signature from both witnesses.? 5. The Medication Disposition Records sent to the Licensing Inspector dated by Staff #1 dated 09/01/2020 for Residents #1, #2, #3, #4, and #5 only contain one signature.
Plan of Correction:	Medications for discharged Residents #1, #2, #3, #4, and #5 disposed of per community policy on 09/01/2020. Executive Director, Resident Care Director, Assistant Resident Care Director, or designee will ensure discontinued medications and discharged residents' medications are disposed of per community policy. Executive Director to review medication management plan with RCD, ARCD, and or designee. [sic]
Standard #:	22VAC40-73-660-A-2
Description:	Based on staff interview and the self report, the facility failed to store medications subject to abuse under a double locked system. EVIDENCE: 1. Staff #1 stated that she observed 70.5 Lorazepam 0.5 mg tablets, 24 Tramadol 50 mg tablets, 66 Clonazepam 0.5 tablets, one container of Morphine Sulfate 100 mg, 29.25 mL; another container of Mrophine 20 mg, 28.75 mL and one container of liquid Lorazepam 2 mg, 30 mL for Residents #1, #2, #3, #4, and #5 being stored in an administrative office, located in an upright cabinet. These are all drugs that are subject to abuse and they were maintained in an unlocked cabinet, in the locked administrative office.
Plan of Correction:	Medications for discharged Residents #1, #2, #3, #4, and #5 disposed of per community policy on 09/01/2020. All narcotic medications will be kept under double lock and key until destroyed by community policy to remain in regulatory compliance. [sic]