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: Sept. 3, 2020 and Sept. 10, 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 09-03-2020 and concluded on 09-10-2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 14. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 3 resident records, facility policies, and IPOC documentation submitted by the facility to ensure documentation was complete. 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 #:	22VAC40-73-640-A
Description:	Based on record review and interview, the facility failed to implement a written plan for medication management to ensure standard operating procedures, including the facility?s standard dosing schedule. Evidence: 1. When asked to provide a copy of the facility?s medication management plan regarding the facility?s standard dosing schedule, staff #1 provided a copy of the facility?s ?Administering Medications? policy. The ?Administering Medications? policy documented ?Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time?? 2. Staff #1 provided copies of resident #1 and resident #3?s most current signed physician?s orders and Medication Administration Records (MAR). The following scheduled medication administration times documented on the MAR?s were not in accordance with the scheduled medication administration times documented on the current signed physician?s orders: A. Resident #1?s current ?Physician?s Order Sheet? dated 05-29-2020 documented an ?8:00 AM? scheduled administration time for Aspirin Low 81mg and Mag Oxide 400mg; however the August and September 2020 MAR documented a scheduled administration time of ?5:00 PM? for the Aspirin Low 81mg and Mag Oxide 400mg. B. Resident #2?s current ?Physician?s Order Sheet? dated 07-01-2020 documented an ?8:00 AM and 8:00 PM? scheduled administration time for Metformin 500mg and Carvedilol 6.25mg, and an ?8:00 AM? scheduled administration time for ?Aspirin Low 81mg, Fexofenadine 180mg, and Vitamin B-12 1000MCG; however, the August and September 2020 MAR documented a scheduled administration time of ?8:00 AM and 5:00 PM? for the Carvedilol 6.25mg and Metformin 500mg; and a scheduled administration time of ?5:00 PM? for the Aspirin Low 81mg, Fexofenadine 180mg, and Vitamin B-12 1000MCG. 3. When asked to provide a copy of the facility?s standard dosing schedule, staff #1 provided a copy of a blank ?Medication Administration Schedule? form. Staff #1 could not provide documentation of the facility?s medication administration schedule. 4. Staff #1, staff #2, and staff #3 acknowledged the facility?s written plan for medication management was not implemented to ensure standard operating procedures to include the facility?s standard dosing schedule for the administration of resident #1 and resident #2?s aforementioned medications.
Plan of Correction:	1. Residents #1, #2 and #3 medication order were not given according to facility medication management plan. 2. All staff in-serviced on Medication administration following physician order. 3. Program Director or designee will perform random medication audit weekly x 4, monthly x 4, quarterly then annually starting 09/30/2021to ensure compliance. 4. Program Director will monitor all staff for accuracy to maintain compliance.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and interview, the facility failed to ensure the physician?s orders for administration of all prescription and over-the-counter medications identified the diagnosis or specific indications for administering each drug. Evidence: 1. Resident #1?s current signed ?Physician?s Order Sheet? dated 05-29-2020 did not include a diagnosis or specific indications for administering Atorvastatin 40mg; Bydureon pen injection 2mg; Insulin Lispro Kwikpen- 100u; or Mag Oxide 400mg. 2. Resident #2?s current signed ?Physician?s Order Sheet? dated 07-01-2020 did not include a diagnosis or specific indications for administering Vitamin D-50,000 units or Furosemide 20mg. In addition, a physician?s telephone order dated 07-09-2020 did not include a diagnosis or specific indication for administering Rybelsus 14mg. 3. Resident #3?s current signed ?Physician?s Order Sheet? dated 02-11-2020 did not include a diagnosis or specific indications for administering Cetirizine 10mg; Fluticasone 50mcg; Losartan 50mg; Sevelamer 800mg; Vitamin D3 50,00 units; Tramadol 50mg; Foltanx RF; or Furosemide 80mg. 4. Staff #1, staff #2, and staff #3 acknowledged the aforementioned physician?s orders for residents #1, #2, and #3 did not include a diagnosis or specific indications for administering each drug.
Plan of Correction:	1. Residents #1, #2 and #3 current signed physician order did not include diagnosis or specific indications for administering Atorvastatin 40mg, Bydureon pen injection 2mg, Insulin Lispro Kwikpen-100u for resident #1; Vitamin D-50,000 units and resident for resident #2; Cetirizine 10mg, Fluticasone 50mcg, Losartan 50mg, Sevelamer 800mg, Vitamin D3 50,00 units, Tramadol 50mg and Foltanx RF for resident #3. 2. All staff were in-serviced on ensuring Physician?s orders include diagnosis or specific indications for administering the medication. 3. Program Director or designee will perform random audit of residents? Medical Records/physician orders (MAR) weekly x 4, monthly x 4, quarterly then annually starting 09/30/2021 to ensure compliance. 4. Program Director will monitor all staff for accuracy to maintain compliance.
Standard #:	22VAC40-73-650-C
Description:	Based on record review and interview, the facility failed to ensure the physician's or prescriber?s oral orders are reviewed and signed by a physician or prescriber within 14 days. Evidence: 1. Staff #1 provided a copy of resident #2?s telephone order dated 07-10-2020 which documented ?D/C Rybelsus 14mg Qday.? The order did not contain a signature from the physician or prescriber within 14 days. 2. Staff #1, staff #2, and staff #3 acknowledged resident #2?s aforementioned telephone order was not reviewed and signed by the physician or prescriber within 14 days and was not signed as of 09-03-2020.
Plan of Correction:	1. Resident #2 Rybelsus 14mg Qday telephone order dated 07/10/2020 was not signed by the physician within 14 days. 2. All staff in-serviced on making sure physician?s orders are reviewed and signed with 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 09/30/2021 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. Evidence: 1. Staff #1 provided a copy of resident #1?s current signed ?Physician?s Order Sheet? dated 05-29-2020 which documented ?Calcium+D3 Tab 315-250- Two tabs by mouth once daily- Supplement.? 2. The Calcium+D3 Tab 315-250 was not documented on resident #1?s August or September 2020 Medication Administration Record (MAR). Staff #1, staff #2, and staff #3 could not provide documentation on file to verify the Calcium+D3 315-250 was administered to resident #1 on 08-01-2020 through 09-01-2020 as ordered by the physician. 3. Staff #1, staff #2, and staff #3 could not provide a physician?s order documenting resident #1?s Calcium+D3 315-250 was discontinued on or after 05-29-2020. 4. Staff #1 provided a copy of resident #3?s current signed ?Physician?s Order Sheet? dated 02-11-2020 which documented ?Vitamin D3 Cap 50000 Unit- Give 1 capsule by mouth twice weekly. Tues & Fri.? 5. Resident #3?s August and September 2020 MAR documented the Vitamin D3 Cap 50000 Unit was administered on Tuesdays and Thursdays on the following days: 08-04-2020, 08-06-2020, 08-11-2020, 08-13-2020, 08-18-2020, 08-20-2020, 08-27-2020, and 09-01-2020. The Vitamin D3 Cap 50000 Unit was not administered on Tuesdays and Fridays as ordered by the physician. 6. Staff #1, staff #2, and staff #3 could not provide an updated physician?s order documenting the administration of the Vitamin D3 Cap 50000 Unit changed to Tuesdays and Thursdays. 7. Staff #1, staff #2, and staff #3 acknowledged resident #1?s and resident?s #3?s aforementioned medications were not administered in accordance with the physician?s instructions.
Plan of Correction:	1. Resident #1 Calcium+D3 were not given according to 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 09/30/2021 to ensure compliance. 4. Program Director will monitor all staff for accuracy to maintain compliance.