VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Journeys Crossing
102 N. Stuart Avenue
Elkton, VA 22827
(540) 298-0054

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: June 10, 2021

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 focused monitoring inspection was initiated on 06/10/21 and concluded on 06/15/21. The administrator was contacted to initiate the inspection. The administrator reported that the current census was 32. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed a selected portion of two resident records submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. Upon receipt of this violation notice, a plan of correction is requested for each violation. The plan of correction should include: 1) steps to correct non-compliance; 2) Measures to prevent reoccurrence of noncompliance; 3) Person(s) responsible for implementing each step and/or monitoring preventative measures; 4) Date by which the noncompliance will be corrected.

Violations:

Standard #:	22VAC40-73-450-D
Description:	Based upon the review of residents' records, the facility failed to ensure the hospice services provided are included on the Individualized Service Plan (ISP). FINDINGS: Residents A and B are receiving hospice services. The services provided are not included on the ISP.
Plan of Correction:	Facility administrator to ensure Individualized Service Plan (ISP) shows all services provided by hospice and updated diet order.
Standard #:	22VAC40-73-680-E
Description:	Based upon review of residents' records, the facility failed to ensure medical procedures ordered by a physician are provided according to his instructions and documented. FINDINGS: 1) Resident A has the following order effective 03/01/21: Check weight weekly. Report weight gain greater than 5lbs in one week. a. Documentation in the electronic Medication Administration Record (MAR) indicates resident refused to be weighed on 05/24/21. There is no documentation in the MAR indicating resident was weighed during the month of May. 2) Resident B has the following order effective 05/13/20: Daily weight: Notify NP if gain of 3lbs in a day or 5lbs in a week. a. There is no weight documented on 05/02/21. b. Documentation on 05/25/21 indicates resident's weight is 147.4lbs c. Documentation on 05/26/21 indicates resident's weight is 153.4lbs. d. There is no documentation of notification to the NP regarding 7lb weight gain.
Plan of Correction:	Facility administrator to ensure that monthly weights are recorded and follow-ups performed if resident refuses on date of monthly weight. Facility administrator to ensure that physician notification is completed if refusal or weight gain/loss per the written order.