VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Discovery Village at the West End
2422 University Park Boulevard
Richmond, VA 23233
(804) 554-1555

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: Dec. 9, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A monitoring inspection was conducted in response to a self-reported incident regarding resident care and related services. The inspection was conducted on December 9, 2021. The census was 67. The Executive Director was onsite on the date of the inspection. Resident records, staff records, and training was reviewed on this date. An Exit interview was conducted on the date of inspection to go over potential non-compliance with the standards.

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on record review and interview with staff, the facility failed to ensure compliance with other relevant regulations and their own policies and procedures. Evidence: 1. The facility?s ?Controlled Substance Accountability? policy documented, ?Supply of control substances should not exceed a 30 day supply?; however, Resident #1?s Tramadol order dated 11-15-2021 documented ?#50? which Staff #1 clarified is an order for 50 count. 2. Staff #1 confirmed during interview that the facility?s ?Controlled Substance Accountability? policy was not followed for Resident #1?s medication.
Plan of Correction:	All community physicians will be notified of the policy to only write prescriptions for a 30-day supply of narcotics. All incoming medications will be audited to ensure compliance going forward.
Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview with staff, the facility failed to ensure that staff who are responsible for administering medications meet the qualification requirements of 22VAC40-73-670. Evidence: 1. The facility?s Medication Administration policy documented, ?Prescription medications that is not self-administered by a resident shall be administered by one of the following: 1. A physician, licensed dentist, licensed physician?s assistant, registered nurse, certified registered nurse practitioner, licensed practical nurse or licensed paramedic or medication technician as defined by State Regulations. 2. A staff person who has completed the medication administration training per state regulation for administration of oral (including inhalers); topical; eye, nose and ear drop prescriptions medications; insulin injections and epinephrine injections for insect bites and other allergies. The administration of medication by a Medication Technician is defined by individual State Regulatory Guidelines.? 2. Staff #2 was hired 9-21-2021. The staff did not have a valid Virginia license to pass medications or meet any of the qualification requirements at the time of hire or during their duration of time working at the facility. Staff #2?s termination date was 11-19-2021. 3. Staff #1 confirmed the facility did not ensure the staff who are responsible for administering medications meet the qualification requirements.
Plan of Correction:	An audit of all Medication Aide licenses was completed on 11/20/2021. Going forward, the ED or designee will audit all staff files within 7 days of their initial start date to ensure compliance with State Regulatory Guidelines.
Standard #:	22VAC40-73-670-1
Description:	Based on record review and interview with staff, the facility failed to ensure when staff administers medications to residents, each staff person who administers medication shall be authorized by ? 54.1-3408 of the Virginia Drug Control Act. All staff responsible for medication administration shall: a. Be licensed by the Commonwealth of Virginia to administer medications; or b. Be registered with the Virginia Board of Nursing as a medication aide. Evidence: 1. Staff #2 was hired on 9-21-2021 as a registered medication aide; however, staff #2 did not provide verification of Virginia licensure. 2. Staff #1 stated that Staff #3 stated the former interim Director of Nursing said it was okay to hire Staff #2 as she was licensed in Pennsylvania, although there was no documentation of that licensure as a medication aide. Staff #2 was not licensed by the Commonwealth of Virginia to license medication and was not registered with the Virginia Board of Nursing as a medication aide.
Plan of Correction:	An audit of all Medication Aide licenses was completed on 11/20/2021. Going forward, the ED or designee will audit all staff files within 7 days of their initial start date to ensure compliance with State Regulatory Guidelines
Standard #:	22VAC40-73-680-B
Description:	Based on record review and interview with staff, the facility failed to ensure medications remained in the pharmacy issued container, with the prescription label or direction label attached, until administered to the resident. Evidence: 1. The following was reported by the facility on 11-17-2021: ??we have another situation of missing narcotics? Yesterday at approximately 4:00pm, we were alerted by our 3-11 med-tech that the count was off for the number of narcotics in the medication cart. After the other incidents, we implemented a count not only for the number of pills in each narcotic package, but a count sheet for the number of narcotics in the cart. On 11/15, 2 cards of Tramadol were delivered for [apartment number]?returned and noticed that the 2nd card of tramadol was missing, that the count was off?? 2. Staff #1 was able to identify that Resident #1?s 1 of 2 Tramadol cards of medication was taken (30 pills).
Plan of Correction:	The associate responsible for the missing medications was terminated from the facility on 11/19/2021. The facility will continue to audit the narcotic count sheets on a weekly basis to ensure all individual narcotic pills as well as full narcotic packages are accounted for.