VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Harmony at Spring Hill
8350 Mountain Larkspur Drive
Fairfax, VA 22079
(571) 348-4970

Current Inspector: Amanda Velasco (703) 397-4587

Inspection Date: Dec. 7, 2020

Complaint Related: Yes

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 complaint inspection was initiated on 12/7/20 and concluded on 2/16/21. A complaint was received by the department regarding allegations in the area of 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. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, 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. Please complete the 'plan of correction' and 'date to be corrected' for each violation cited on the violation notice and return to the licensing office within 10 calendar days. Please specify how the deficient practice will be or has been corrected. Just writing the word 'corrected' is not acceptable. The 'plan of correction' must contain: 1) Steps to correct the non-compliance with the standards, 2) Measures to prevent the non-compliance from occurring again, and 3) Person responsible for implementing each step and/or monitoring any preventative measures. Thank you for your cooperation and if you have any questions, please contact me via e-mail at m.massenberg@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-640-A
Complaint related:	Yes
Description:	Based on record review, the facility failed to implement the medication management plan. Evidence: Resident #1 was admitted to the facility on 10/26/20. The facility also received Resident #1's updated medication orders, dated 10/26/20. Among the medications, on the 10/26/20 orders, were Atorvastatin 20mg, Vitamin D3 1000U, and Omeprazole 20mg. The facility?s medication management plan calls for new orders to be transcribed within 24 hours to the Electronic/Medication Administration Record (EMAR) and reviewed by a licensed nurse or designee. Resident #1?s EMAR did not include the resident?s Atorvastatin 20mg, Vitamin D3 1000U, and Omeprazole 20mg. There was no documentation to indicate that the medications were administered from 10/26/20 until the resident left the facility on 10/31/20. The facility?s medication management plan calls for all EMARs to contain the signatures and initials of all appropriate staff members administering medications from that EMAR. The plan goes on to state that the EMAR will be reviewed by the off-going and on-coming nurse/RMA to ensure all medications, supplements and/or treatments have been completed. The EMAR did not contain staff documentation for Resident#1's blood sugar check or Humalog administration on 10/27/20 (4:30 PM administration).
Plan of Correction:	Healthcare Director/Designee will verify that all new orders are entered correctly into the EMAR system. Nurses/RMA will report EMAR discrepancies at shift change to Health Care Director/Designee. Healthcare Director/Designee will verify that all new orders are entered correctly into the EMAR system. Healthcare Director/Designee shall verify orders with EMARs at time of implementation. Nurses/RMA will report EMAR discrepancies at shift change to Health Care Director/Designee. Helathcare Director/Designee will monitor EMARs daily x 4 weeks and then randomly.
Standard #:	22VAC40-73-680-D
Complaint related:	Yes
Description:	Based on record review, the facility failed to ensure that medications are administered in accordance with physician's or other prescriber'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: Resident #1?s record contained an order for Humalog, dated 10/26/20. The order called for Resident #1 to receive Humalog before meals. Resident #1 was administered Humalog on 10/29/20 (4:30 PM) when the resident?s blood sugar was documented as 49. Humalog patient information includes a warning that states: Do not take HUMALOG if you are having an episode of low blood sugar (hypoglycemia). The website for the Centers for Disease Control and Prevention includes the following about low blood sugar: Blood sugar levels change often during the day. When they drop below 70 mg/dL, this is called having low blood sugar.
Plan of Correction:	Nurse/RMA received training/education on diabetic medication administration on 11-16-2020. Nursing staff shall receive education at orientation and ongoing on medication management. Healthcare Director/Designee shall verify orders with EMARs at time of implementation. Healthcare Director/Designee shall audit EMARs daily x 4 weeks and then randomly.