VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carriage Hill Retirement
1203 Roundtree Drive
Bedford, VA 24523
(540) 586-5982

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 6, 2021

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 The Criminal History Record Report 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 05/06/2021 and concluded on 05/12/2021. A complaint was received by the department regarding allegations in the areas of infection control, resident care and related services, staffing and supervision and the criminal history record report. 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. To ensure that the facility had an thorough understanding of standards, the licensing inspector, the Vice President and the Administrator had a discussion regarding standard 100 A. The evidence gathered during the investigation did not support the allegations of non-compliance with standards or law. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-100-A
Complaint related:	No
Description:	Based on document review, the facility failed to ensure that the infection control program included all required components. EVIDENCE: 1. The facility?s infection control program provided to the licensing inspector for review does not contain the following requirements: the sanitation of rooms, including cleaning and disinfecting procedures, agents and schedules and that when recommendations are made by the Virginia Department of Health to prevent or control transmission of an infectious agent in the facility, the recommendations must be followed.
Plan of Correction:	1. The facility will update the Infection Control Program to include sanitation of rooms, including cleaning and disinfecting procedures, agents and schedules and that when recommendations are made by the Virginia Department of Health to prevent or control transmission of an infectious agent.
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 medication management plan states ?Each controlled substance will be tracked using a separate Controlled Medication Log which meets the requirements of state and federal narcotic enforcement agencies. At the end of each shift, the outgoing and incoming RN, LPN, or RMA authorized to administer medications, will count all controlled substances and sign the Controlled Medication Log verifying the count is accurate.? 2. The ?Shift to Shift Narcotic Count Sign off Sheet? for medication cart ?D? for May 2021, does not contain the signature of the registered medication aide (RMA) going off duty (11p-7a Leaving) for the dates of 05/04/2021 and 05/06/2021, the RMA going off duty (3p-11p Leaving) for 05/03/2021 and the on-coming RMA (11p-7a Coming) for the dates 05/03/2021 and 05/05/2021.
Plan of Correction:	1. Director of Nursing / Administrator will ensure Medication Log is signed off by each shift.