VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hope Haven
24532 Prince Edward Highway
Rice, VA 23966
(434) 392-9276

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 24, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Comments:

Type of inspection: Renewal Date of inspection and time the licensing inspectors were on-site at the facility for each day of the inspection: 05/24/2022 9:26AM through 1:45PM. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 6 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on observation of the facility?s medication storage containers and document review, the facility failed to implement their medication management plan. EVIDENCE: 1. The facility?s medication management plan indicates the following: ?3. Methods to prevent the use of outdated, damaged, or contaminated medications. All medication will be inspected upon delivery and subsequently to ensure that they are not outdated, damaged or contaminated.? and ?Administrator, or designated Assistant or Manager, will monthly audit all medication to ensure compliance of policy and conformance to this plan by Registered Medication Aides (RMA).? 2. The facility?s medication storage containers contained the following expired medications: Nystatin powder for Resident 1that expired in December 2021, Mylanta for Resident 3 that expired on 04/07/2022 and Anti-itch cream that expired in October 2021, and Epinephrine injection pens for Resident 5 that expired in April 2020 and March 2021.
Plan of Correction:	The Administrator and ALF Coordinator reviewed 22VAC40-73-640-A, the noted violation, and Hope Haven?s Medication Management Plan. The Administrator and ALF Coordinator completed an audit of all medication containers and current prescriptions to identify expiration dates, inventory current medication and said dates, and order refills as needed for any medications nearing expiration. The Administrator and ALF Coordinator reviewed the inspection violations and Medication Management Plan with all Registered Medication Aides along with current inventory lists/expiration dates. The Administrator and ALF Coordinator will conduct monthly and bi-weekly audits of all medication containers to prevent future violations and ensure all expired medications are replaced and disposed of per Hope Haven?s Medication Management Plan.
Standard #:	22VAC40-73-680-K
Description:	Based on observation of the facility?s medication storage containers, the facility failed to ensure that a PRN (as needed) medication contained a detailed order from the resident?s physician or other prescriber for medication aides to be able to administer a PRN medication. EVIDENCE: The facility does not employee licensed health care professionals as confirmed by staff 4. The facility?s medication storage container contained a box of Narcan 4mg Nasal Spray for resident 6; however, the medication did not include a detailed medication order from the resident?s physician or other prescriber that included the following: symptoms that indicate the use of the medication, exact dosage, the exact time frames the medication is to be given in a 24-hour period and directions as to what to do if symptoms persist.
Plan of Correction:	The Administrator and ALF Coordinator reviewed 22VAC40-73-680-K.3, the noted violation, Hope Haven?s Medication Management Plan, and the noted resident?s PRN for Narcan. The ALF Coordinator contacted the resident?s prescribing physician and requested a new order for the noted medication with all required instructions per standard. The Administrator and ALF Coordinator reviewed all current PRN orders for all residents to ensure each order contained all required information and instructions. New orders were requested as needed. The Administrator and ALF Coordinator reviewed the violation and medication management plan with all facility RMAs and DSPs to review the requirements and expectations regarding all potential prescriptions received during medical appointments. The Administrator and ALF Coordinator will conduct monthly audits of all PRN orders and review any new PRN order received prior to ensure all information and instructions are present before placing in the resident?s records/medication containers. In addition, the ALF Coordinator contacted the facility?s pharmacy and reviewed the noted standard in order to address any potential orders received via electronically by the pharmacy and orders detailed and clarified prior to sending to the facility.
Standard #:	22VAC40-73-680-M
Description:	Based on observation of the facility?s medication storage containers and staff interview, the facility failed to ensure that medications ordered for PRN (as needed) administration were available at the facility. EVIDENCE: The record for resident 3 contained a physician?s order, dated 12/08/2021 ? 12/08/2022, for the following medications: Acetaminophen, SM Tussin, Cough drops, Chloraseptic spray, Chlorpheniramine, Tums, Simethicone, Loperimide, Milk of Magnesia, Triple anti-biotic ointment, Hydrocortisone Cream, and Vitamin A&D ointment. The aforementioned medications were not available at the facility during the on-site inspection and this was confirmed by staff 5.
Plan of Correction:	The Administrator and ALF Coordinator reviewed 22VAC40-73-680-M, the noted violation, Hope Haven?s Medication Management Plan, and all current PRN orders on hand for all residents. The Administrator and ALF Coordinator reviewed the current PRN orders and yearly OTC forms. The ALF Coordinator contacted Bremo LTC Pharmacy to refill all noted PRN orders that were not on hand at the time of the inspections. In addition, the ALF Coordinator contacted each resident?s prescribing physician and requested new orders for all applicable PRNS rather than utilizing the OTC form that contained a list of potential OTC medications that may be needed. The Administrator and ALF Coordinator ensured that all PRN orders were reviewed and all medications prescribed were on hand or ordered for refill. The Administrator and ALF Coordinator reviewed the violation and medication management plan with all facility RMAs to ensure that PRN medications are refilled in a timely manner and on hand at the facility at all times per standard. The Administrator and ALF Coordinator will conduct monthly and bi-weekly audits of all PRN inventories as noted in previous plan of corrections above.