VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Indian River Assisted Living
1012 Justis Street
Chesapeake, VA 23325
(757) 523-4659

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date:

Complaint Related: No

Violations:

Standard #:	22VAC40-73-480-C
Description:	Based on record review and discussion, the facility failed to arrange for specialized rehabilitative services by qualified personnel as needed by the resident. Rehabilitative services include physical therapy, occupational therapy, and speech-language pathology services. Evidence: 1. Resident #1 admitted to the hospital on 12-20-2020 according to ?Discharge Summary? that documented, ?Of note, case management reports that this is living facility is not allowing outside home health, but this should be considered when possible? Disposition: Return to ALF [assisted living facility] recommend home health services.? The Summary was signed by [Hospital Physician #1] on 12-28-2020. 2. Resident #4 admitted to the hospital on 12-17-2020 according to ?Discharge Summary? that documented, ?The patient is temporarily homebound due to weaknes secondary to covid. PT [physical therapy] is needed to regain mob. SN [skilled nursing] is needed to perform diabetes management. OT [occupational therapy] is needed to equipneeds?? This was signed by [Hospital Physician #2] on 12-23-2020. 3. Rehabilitative services notes were not provided for Resident #1 or Resident #4?s record. Staff #2 stated due to COVID-19, they were not allowing therapy services in the building at this time until 02-08-2021; however, there was no discontinued order for rehabilitative services that were recommended.
Plan of Correction:	IRAL will implement a new binder for home health only. An audit will be conducted on all residents who returned from the hospital starting on 12/1/2020. All resident MARs and TARs will be audited for any discharged orders. The home health binder will be audited monthly for all new orders, discharged orders and make sure that any new orders are complete before being faxed to the Pharmacy.
Standard #:	22VAC40-73-650-B
Description:	Based on record review and discussion, the facility failed to ensure physician or other prescriber orders identified the diagnosis, condition, or specific indications for administering each drug. Evidence: 1. Resident #2?s physician?s orders dated 01-08-2021 did not identify the diagnosis for Duloxetine HCL DR 30 mg cap, Isosorbide MN ER 60 MG tablet, Multi-Day Plus Iron, Oxycodone-Apap 5-325, Rosuvastatin Calcium 20 mg tab, and Victoza 18 mg/3 ML Inject P. 2. Staff #2 confirmed Resident #2?s latest signed orders did not contain all if the required information.
Plan of Correction:	Going forward, all new orders will be reviewed for completeness including diagnosis. The RCC or ARCC will check off before new order is faxed to the pharmacy.