VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Shenandoah Place, Inc.
50 Burkholder Lane
New market, VA 22844
(540) 740-4300

Current Inspector: Laura Lunceford (540) 219-9264

Inspection Date: Aug. 6, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated self-report inspection was initiated on 08/06/21 and concluded on 08/19/2021. A self-reported incident was received by the department relating to medication management. The acting administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the acting administration a list of documentation required to complete the investigation The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and violations were issued. Any violations not related to the/self-report but identified during the course of the investigation can be found on the violation notice. 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 re-occurrence; 3) person(s) responsible for implementing each step and monitoring preventative measures; 4) the date by which the non-compliance will be corrected

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on document review and an interview, the facility failed to implement a written plan for medication management to ensure medications are refilled in a timely manner. EVIDENCE: 1. The acting administrator reported to the licensing office on 07/23/21 that resident 1 did not receive three doses of scheduled medication due to medication not being available for administration. 2. The July 2021 Medication Administration Record (MAR) for resident 1 indicates Oxycodone was not available for administration on 07/18/21 at 6:00pm; 07/19/21 at 6:00am and 12:00pm. 3. Interview with acting administrator on 08/06/21 at 4:56pm confirmed medication was not available for administration.
Plan of Correction:	RMA supervisor is assigned to re-order medications in a timely manner according to the medication administration plan and report any potential difficulty with the process. Administrator will review medication re-orders with RMA supervisor once weekly to ensure that physician's orders are up to date and medications are on hand.