VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Highland House
3501 Longdale Furnace Road
Clifton forge, VA 24422
(540) 862-4271

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Jan. 5, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION.

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 complaint inspection was initiated on 01/05/2021 and concluded on 01/25/2021. A complaint was received by the department regarding allegations in the areas of personnel, staffing and resident care and related services. 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. A discussion was held between the licensing inspector and the administrator to ensure that the facility had a thorough understanding of standard 640 A, 640 B and 640 C. Based on the evidence gathered during the investigation one area of the complaint was founded and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on document review, the facility failed to ensure accurate counts of all controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. The facility?s current medication management plan, ?American Retirement Homes, Inc. Highland House Medication Management Plan? states ?An assigned Licensed Nurse/ Registered Medication Aide will begin a shift by completing a controlled drug count. Controlled drugs will be kept under double lock. Two Licensed Nurse/Registered Medication Aides will do the count of each controlled drug, one accounting for the actual number/ amount of the drug, the other verifying the number/ amount recorded as being available on the control sheet. A control drug count sheet is to be signed by individual going off duty, and the one accepting the responsibility for the control drugs, and medication administration.? 2. The ?CONTROLLED DRUGS ? COUNT RECORD HIGHLAND HOUSE? for December 2020 and January 2021, does not contain the signature of the registered medication aide going off duty (11 ? 7 Shift) on the 7 ? 3 shift for the dates of 12/01/2020 through 12/31/2020, 01/01/2021 through 01/07/2021 and 01/09/2021 through 01/13/2021. The ?CONTROLLED DRUGS ? COUNT RECORD HIGHLAND HOUSE? for December 2020 does not contain the signature of the registered medication aide going off duty (7 ? 3 shift) on the 3-11 shift on 12/02/2020 and 12/06/2020 and the 11-7 shift on 12/02/2020, 12/09/2020, 12/11/2020, 12/12/2020, 12/22/2020, 12/29/2020. 3. The ?CONTROLLED DRUGS ? COUNT RECORD HIGHLAND HOUSE? does not contain a signature of the registered medication aide going off duty or the registered medication aide accepting responsibility for the controlled drugs and medication administration for the 7-3 Shift on 01/08/2021.
Plan of Correction:	The controlled count sheet was updated to ensure that the registered medication aide will be signing when counting controlled substances at the beginning and at the end of their shifts. This began being utilized on 1/27/2021.
Standard #:	22VAC40-73-650-A
Complaint related:	Yes
Description:	Based on resident record review and staff interview, the facility failed to ensure medications were not changed without a valid order from a physician or other prescriber. Medications include prescription, over-the-counter, and sample medications. EVIDENCE: 1. Physician?s orders for resident 1, dated 09/29/2020, showed ?LEVOTHYROXINE 100 MCG TABLET Generic for: SYNTHROID 100 MCG TAB* TAKE ONE TABLET BY MOUTH**OWN MEDS USE UP** EVERY DAY FOR THYROID? and time to be administered at 6:00AM. The December 2020 medication administration record (MAR) for resident 1 showed that the scheduled time for Levothyroxine to be administered was changed from 6:00 AM to 6:30 AM on 12/30/2020. The January 2021 MAR showed that the medication was still scheduled to be administered at 6:30 AM as of 01/13/2021. 2. Physician?s orders for resident 2, dated 09/29/2020, showed ?LEVOTHYROXINE 75 MCG TABLET Generic for : SYNTHROID 75 MCG (0.075 MG) TAKE ONE TABLET BY MOUTH EVERY DAY ON AN EMPTY STOMACH FOR THYROID REPLACEMENT? and time to be administered at 6:00AM. The December 2020 MAR showed that the scheduled time for Levothyroxine to be administered was changed from 6:00 AM to 6:30 AM on 12/30/2020. The January 2021 MAR showed that the medication was still scheduled to be administered at 6:30 AM as of 01/13/2021. 3. Physician?s orders for resident 3, dated 09/29/2020, showed ?FLUTICASONE PROP 50 MCG SPRAY Generic for: FLONASE 0.05% NASAL SPRAY SPRAY 1 SPRAY INTO EACH NOSTRIL 2 TIMES A DAY FOR ALLERGIC RHINITIS? and time to be administered at 8:00 AM. The December 2020 MAR showed that the scheduled time for Fluticasone to be administered had been changed from 8:00 AM to 6:15 AM on 12/16/2020. The January 2021 MAR showed that the medication was still scheduled to be administered at 6:15 AM as of 01/13/2021. 4. Interview with staff 1 revealed that staff 1 changed the medication times on the December 2020 MARs for residents 1, 2 and 3 but was not able to provide physician?s orders that reflected the change in administration time.
Plan of Correction:	Updated physician order forms to reflect new administration times were obtained on 2/17/2021. Staff will ensure an order is received to adjust administration times before adjusting.