VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Bickford of Virginia Beach
2629 Princess Anne Road
Virginia beach, VA 23456
(757) 821-0198

Current Inspector: Willie Barnes (757) 439-6815

Inspection Date: April 7, 2022 , April 26, 2022 , May 4, 2022 and May 11, 2022

Complaint Related: No

Areas Reviewed:

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 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Comments:

Type of inspection: Renewal On-site renewal inspection was conducted with two inspectors from the Peninsula Licensing Office on 4-7-22 (Ar 07:45 /dep 4:55 p.m). The facility census was 61, a tour of the facility was conducted, medication pass observation, activity, emergency preparedness/ first aid kit check, resident and staff records and interview conducted. A preliminary exit conducted with administrator and assistant resident coordinator on 4-7-22. Requested documents received on 4-26-22, exit and review conducted on 5-4-22 with administrator, nursing coordinator and assistant resident coordinator, final exit interview conducted on 5-11-22 with administrator and nursing coordinator. Final exit interview with renewal inspection documents conducted on 6-6-22. The Acknowledgement of Inspection form was sent to the Administrator following each exit meeting and receipt of documents. 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. 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 (Willie Barnes), Licensing Inspector at (757-439-6815) or by email at willie.barnes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1110-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure whenever warranted by a change in a resident?s condition, the licensee, administrator, or designee shall also perform a review of the appropriateness of continued placement in the unit. Evidence: 1. On 4-7-22, resident #1 was observed receiving service outside of the safe, secure unit. Staff #1 stated the resident was first placed on the unit when admitted to the facility. The resident was later determined to not need to be on the safe, secure unit. Resident was relocated to the assisted living (AL) unit. The facility Matix Care 2022, Resident Census document noted resident relocated to the AL unit of the facility on 3-29-22. The resident?s record did not include documentation of reassessment by the facility.
Plan of Correction:	*Resident #1 Medical Record currently contains all reassessment documentation required for a level of care change from the Special Care Unit to Assisted Living. *Those trained and designated to complete and update the UAI, Service Plans, and other reassessment documentation, as scheduled or indicated, have been instructed to obtain the Director?s signature and file the finalized document in the resident?s medical record immediately following completion. *During future on-site inspections and monitoring visits, a member of the Directing Family Group will accompany the Licensing Inspector during the medical record review to assure that all documents are located within the medical record or retrieved from the location where they are maintained. Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
Standard #:	22VAC40-73-1140-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure within four months of starting employment in the safe, secure, environment, direct care staff shall attend at least 10 hours of training in cognitive impairment that meets the required of the 22VAC40-73-1140-C. Evidence: 1. Staff #4 did not have documentation of 10 hours of cognitive training within 4 months of hire, staff?s record document 3 hours of dementia training (12-8-20). Staff?s date of hire was documented as 12-1-20. 2. Staff #8?s record documented 9 hours 15 minutes of cognitive training within 4 months of hire. Staff?s date of hire was documented as 10-11-21.
Plan of Correction:	*Staff #4 & #8 training records were audited to assure that their current training requirements are up to date. *Requested training records to printed, by date range, starting on their hire/anniversary date thru the date prior to their anniversary date of the following year to assure that the correct training dates/content are reflected on their training record. *This will be monitored during monthly training record audits and reviewed weekly by the Directing Family Group and the results reported for Divisional Review. Person Responsible: Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
Standard #:	22VAC40-73-100-C-2
Description:	Based on observation and staff interviewed, the facility failed to ensure it followed its infection control program. Evidence: 1. On 4-7-22 during medication pass observation with staff #3, a check of resident #1?s glucose equipment was completed. The resident?s auto/needle injector on the medication cart was not labeled with the resident?s name. 2. Staff #3 acknowledged the aforementioned resident?s glucose injector was not labeled.
Plan of Correction:	*Resident #1 had his lancet device properly labeled by the NCC. *All other residents receiving accu-checks had their lancet devices to ensure that they were properly labeled. *All RMAs will be educated on proper labeling of all medication related devices. Those items will be labeled at the time of receipt. * This will be monitored during the weekly medication audits. * The findings from those audits will be reviewed weekly by the Directing Family Group and the results reported for Divisional Review. Person Responsible: NCC/ACC/Divisional Leadership Target Completion Date: 6/16/22 & ongoing
Standard #:	22VAC40-73-210-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure at least two of the required hours of training shall focus on infection control and prevention. When adults with mental impairments resident in the facility, at least four of the required hours shall focus on topics related to residents? mental impairments. Evidence: 1. Staff #1?s record did not include documentation of annual infection control and prevention training. Staff?s date of hire documented as 11-21-19. 2. Staff #3?s record documented 1 hour of infection control and prevention (8-28-21), staff?s date of hire was dated as 10-7-19. 3. Staff #4?s infection control document dated 12-1-21 did not document hours of training. Staff?s date of hire was dated 12-1-20.
Plan of Correction:	*The annual training outline was reviewed and updated to include additional training in the area of infection control. All newly hired staff will be required to complete this as a part of their initial new hire training and annually thereafter. *The 1 hour Infection Control training received along with the Annual Med Tech Refresher course will be scheduled within 1 year of when it was last offered at the Branch to assure that it is received within 12 months of when it was last scheduled. *This will be monitored during monthly training record audits and reviewed monthly by the Directing Family Group and the results reported for Divisional Review. Person Responsible: NCC/ACC/Divisional Leadership Target Completion Date; 6/16/22 & ongoing
Standard #:	22VAC40-73-250-D
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, documenting the absence of tuberculosis (TB) in a communicable form as evidences by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: 1. Staff #6?s TB screening documentation was dated 11-30-21 by staff #10. Staff?s date of hire was dated 11-22-21. The document from a local treating clinic was dated 9-7-20.
Plan of Correction:	*All newly hired staff provide their most recent TB results at the time of hire or receive testing. Those providing test previous test results also receive a screening performed by the Nursing Coordinators. *The Branch will update their records to include written consent from the Doctor/Nurse Practitioner to perform routine TB screenings using the DSS or VDH approved form. *This authorization will be updated, as required, to include those currently authorized to complete this task. Person Responsible: NCC/ACC/Divisional Leadership Target Completion Date: 6/30/22 & ongoing
Standard #:	22VAC40-73-290-A
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the staff?s written schedule include all required information. Evidence: 1. The April 2022 dietary schedule received on 4-12-22 documented only the first name or partial name of staff members. The schedule did not document staff?s job classification. 2. The written work schedules provided did not include an indication of whomever is in charge at any given time.
Plan of Correction:	*The Kitchen Manager begun using an Excel Spreadsheet schedule template on 5/29/22 that will include the staff member?s full name and position being worked on each scheduled shift. *The monthly schedule will be reviewed monthly by the Director, prior to posting, to assure that all required information is included Person Responsible: KM/Dir/Divisional Leadership Target Completion Date:
Standard #:	22VAC40-73-380-B
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the resident?s personal and social information placed in resident?s record was kept current for three of nine records reviewed. Evidence: 1. On 4-7-22, resident #?1s record included a copy of the resident?s ?Do Not Resuscitation (DNR)? document signed and dated 1-24-22 by the physician. The resident?s ISP dated 1-17-22 documented the resident as a ?Full Code?. The resident?s personal and social data document also noted resident as a ?Full Code?. 2. On 4-7-22, resident #7?s record included a copy of the resident?s DNR dated 6-17-20. The personal and social data document noted resident as a ?Full Code?. 3. On 4-7-22, staff #1 acknowledged the aforementioned residents? social data/personal sheet documented- face sheet documented residents as a ?Full Code?.
Plan of Correction:	*Resident #1 had the code status updated on the Service Plan. *Resident?s #1 & #7 had their current code status updated on the Resident Face Sheet (Personal/Social Data Sheet). *All resident records will be audited to determine code status. That information will be added/updated on the Resident Face Sheet, Service Plan, and other required locations within the medical record, if needed. *This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC & Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
Standard #:	22VAC40-73-410-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure upon admission, the facility provided an orientation for new residents and their legal representative for three of nine records reviewed. Evidence: 1. On 4-7-22 resident #1?s record documented the resident?s orientation to the facility was signed and dated by the representative on 2-10-22. The resident?s record documented the date of admission as 2-1-22. 2. On 4-7-22 resident #4?s record did not include documentation of orientation. Resident?s date of admission in record was dated 2-25-21. 3. On 4-7-22 resident #9?s record did not include documentation of orientation. Resident?s date of admission in record was dated 11-1-21.
Plan of Correction:	*Resident #1 completed a bed-hold agreement from 1/17/22 ? 2/9/22. His physical move in date was 2/10/22, and the medical record was reviewed to assure that this date is accurately reflected. *Resident #1 copy of the Orientation Check List, signed at dated on 2/10/22, is located in the medical record behind the ?Social? tab divider. The original is located in the Administrative Record. * Resident #4 copy of the Resident Orientation Checklist, signed and dated on 2/25/21, is located in the medical record behind the ?Social? tab divider. The original is located in the Administrative Record. *Resident #9 copy of the Resident Orientation Checklist, signed and dated on 11/1/21, is located in the medical record behind the ?Social? tab divider. The original is located in the Administrative Record. Person Responsible: NCC/ACC,Dir./CRD/Divisional Leadership Target Completion Date: 6/6/2022 & ongoing
Standard #:	22VAC40-73-440-A
Description:	Based on record review and staff interviewed, the facility failed to ensure prior to admission, the resident should be assessed face-to-face using the uniformed assessment instrument (UAI) in accordance with the Assessment in Assisted Living Facilities (22VAC30-110) for three of nine records reviewed. Evidence: 1. On 4-7-22, resident #6?s record did not include a UAI. The resident?s record documented date of admission was 1-17-22. 2. On 4-7-22, resident #8?s record did not include a UAI. The resident?s record documented date of admission was 4-5-22. 3. On 4-7-22, resident #9?s record did not include a UAI. The resident?s record documented date of admission was 11-1-21.
Plan of Correction:	*Resident #6 UAI, signed and dated by staff members #1 & #10 on 1/12/22, is located in the medical record under the ?Service Assessment? tab divider. *Resident #8 has been discharged. The closed records contain the UAI in question. *Resident #9 has been discharged. The closed records contain the UAI in question. *All current resident Medical Records will be audited to assure that each contains the appropriate/current UAI and that Bickford?s Chart Thinning Policy is being followed with regards to transferring documents to thinned records files maintained on site. * During future on-site inspections and monitoring visits, a member of the Directing Family Group will accompany the Licensing Inspector during the medical record review to assure that all documents are located within the medical record or retrieved from the location where they are maintained. *Those trained and designated to complete and update the UAI, as scheduled or indicated, have been instructed to obtain the Director?s signature and file the finalized document in the resident?s medical record immediately following completion. * This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
Standard #:	22VAC40-73-440-H
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure an annual reassessment, using the uniformed assessment instrument (UAI) shall be utilized to determine whether a resident?s needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: 1. On 4-7-22, resident #3?s resident did not include documentation of a uniformed assessment instrument (UAI). The record documented the resident?s date of admission was 3-5-21. 2. On 4-7-22, resident #4?s record did not include documentation of a UAI. The record documented the resident?s date of admission was 2-25-21, the UAI in the record was dated 3-23-21 and signed by staff #1 and #10.
Plan of Correction:	*Resident?s #3 & #4 have the appropriate/current UAI in the Medical Record. *All current resident Medical Records will be audited to assure that each contains the appropriate/current UAI and that Bickford?s Chart Thinning Policy is being followed with regards to transferring documents to thinned records files maintained on site. *During future on-site inspections and monitoring visits, a member of the Directing Family Group will accompany the Licensing Inspector during the medical record review to assure that all documents are located within the medical record or retrieved from the location where they are maintained. *Those trained and designated to complete and update the UAI, as scheduled or indicated, have been instructed to obtain the Director?s signature and file the finalized document in the resident?s medical record immediately following completion. * This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
Standard #:	22VAC40-73-440-K
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the uniformed assessment instrument (UAI) was in compliance with requirements set forth in 22VAC40-30-110. Evidence: 1. On 4-7-22, resident #1?s uniformed assessment instrument (UAI) dated 2-6-22 (2-10-22) was completed and signed by facility representative # 9, but was not signed by the facility administrator or a designee.
Plan of Correction:	*Resident #1 UAI update/reassessment completed on 2/6/22 by staff #9 was reviewed and signed by the facility Administrator on 6/13/22. *All current resident Medical Records will be audited to assure that each contains UAIs that have been reviewed and signed by the Administrator or Designee. *Those trained and designated to complete and update the UAI, as scheduled or indicated, have been instructed to obtain the Director?s signature and file the finalized document in the resident?s medical record immediately following completion. * This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
Standard #:	22VAC40-73-450-C
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) included all assessed needs for six of nine residents. Evidence: 1. On 4-7-22, resident #1?s record did not include documentation of a comprehensive individualized service plan (ISP). The record include a preliminary plan of care completed 1-17-22 by facility staff #10 and signed by the resident?s legal representative on 2-10-22. The resident?s date of admission to the facility was documented as 2-10-22, facility document Matrix Care- Resident Census, submitted on 5-6-22 resident?s admit change date to facility?s safe, secure unit. 2. On 4-7-22, resident #2?s record documented resident receiving psychological services from a local agency. Documentation were dated 3-8-22 and 4-5-22. These services were not documented on the resident?s ISP dated 9-23-21. The resident?s April 2022 medication administration record documented resident keeps Systane Gel eye drops and Zicam nasal spray at bedside. The resident?s uniformed assessment instrument (UAI) dated 9-23-21 documented medication administered by facility staff. Resident?s UAI documented wheeling and stairclimbing ?not performed: the ISP did not include who would perform services, how and where. The aforementioned services were not documented on the resident?s ISPs dated 9-23-21 and Care Plan dated 3-11-22 (180 day assessment submitted on 5-6-22). 3. Resident #3?s ISP dated 8-24-21 and 3-18-21 did not include resident?s physical therapy services (4-4-21 and discharged 5-17-21); occupational therapy (4-8-21 and discharged 5-17-21) and speech therapy services (3-31-21 and discharged 5-5-21). Resident?s record included documentation resident wears trifocal eye glasses. This information was not documented on resident?s preliminary ISP dated 2-19-21, ISP dated 3-28-21 and ISP dated 8-24-21. 4. Resident #4?s ISP dated 8-28-21 did not include resident?s psychological services. The record noted services provided by an agency on 9-20-21 (initial services); additional dates of services documented in the record: 9-28-21; 12-14-21; 1-11-22; 3-8-22 and 4-5-22. The uniformed assessment instrument (UAI) dated 3-23-21 documented wheeling and stairclimbing not performed. The wheeling and stairclimbing needs were not documented on the ISP dated 8-28-21. 5. Resident #6?s admission physical examination dated 1-13-22 documented the following allergies: Codeine, Gabapentin, Hydrocodone, Oxycodone and stimulant laxative. This information was not documented on the resident?s ISP dated 1-22-22 and 2-10-22. 6. Resident #9?s record included copy of Do Not Resuscitate (DNR) dated 11-4-21, this information not documented on the ISP.
Plan of Correction:	*Resident #1 Service Plan, reflecting the level of care change to Assisted Living from MBs is located in the Medical Record. *Resident #9 has been discharged. *Resident?s #2, #3, #4, & #6 Service Plans were updated to include the information/services referenced in this report. *All current resident Service Plans will be modified as care and services are added or updated and during scheduled re-assessments. *This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date:6/30/2022 & ongoing
Standard #:	22VAC40-73-450-F
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure the individualized service plan (ISP) was reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition for three of nine records reviewed. Evidence: 1. On 4-7-22, resident #2?s individualized service plan documented an end date (review) of 3-2022. The ISP in the record was signed and dated by the developer, administrator and resident on 9-23-21. The resident?s record documented the date of admission was 9-22-20. 2. On 4-7-21, resident #3?s ISP dated 3-18-21 documented an end date (review) of 9-2021. The record included a preliminary dated 2-19-21 by facility staff and 3-6-21 by the legal representative. The record did not include a current ISP. The record documented the date of admission was 3-5-21. 3. On 4-7-22, resident #4?s ISP dated 8-28-21 documented an end date (review) of 2-2022. The record did not include a current ISP. The resident?s record documented date of admission was 2-25-21.
Plan of Correction:	*Resident?s #2, #3, & #4 have the appropriate/current Service Plans in their Medical Records. *All current resident Medical Records will be audited to assure that each contains the appropriate/current Service Plans and that Bickford?s Chart Thinning Policy is being followed with regards to transferring documents to thinned records files maintained on site. *During future on-site inspections and monitoring visits, a member of the Directing Family Group will accompany the Licensing Inspector during the medical record review to assure that all documents are located within the medical record or retrieved from the location where they are maintained. *This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
Standard #:	22VAC40-73-470-A
Description:	Based on record reviewed and staff interviewed, the facility failed to ensure, either directly or indirectly, that the health care service needs of residents are met. Evidence: 1. On 4-7-22, resident #1?s physical examination dated 1-21-22 documented Physical Therapy recommended. The resident?s record did not include documentation of physical therapy evaluation and/or services provided. 2. On 4-7-22, resident #3?s physical examination dated 3-3-21 documented Physical therapy, Occupational therapy and Speech therapy evaluate and treat. The record did not include documentation of therapy services or an evaluation. The ISP dated 3-18-21 did not include documentation of therapy services. 3. On 4-7-22, resident #4?s physical examination updated 2-25-21 documented Physical therapy recommended. The record also included a physician?s order signed and dated 3-11-21 for physical therapy, occupational therapy and speech therapy. The record did not include documentation of an evaluation or services provided. The individual service plan (ISP) dated 8-28-21 in the record did not document services received or achieved outcome date.
Plan of Correction:	*Resident?s #1, #3, & #4 Medical Records contain any current Physical, Occupational and Speech Therapy evaluations and notes as outlined in Bickford?s Chart Thinning Policy. *All current resident Medical Records will be audited to assure that they contain any current Physical, Occupational and Speech Therapy evaluations and notes and that Bickford?s Chart Thinning Policy is being followed with regards to transferring documents to thinned records files maintained on site. *During future on-site inspections and monitoring visits, a member of the Directing Family Group will accompany the Licensing Inspector during the medical record review to assure that all documents are located within the medical record or retrieved from the location where they are maintained. *This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
Standard #:	22VAC40-73-580-D
Description:	Based on record review and staff interviewed, the facility failed to ensure when the uniformed assessment instrument (UAI) assessed resident as dependent in eating/feeding, the individualized service plan (SIP) shall indicate an approximate amount of time needed for meals to ensure needs are met. Evidence: 1. On 4-7-22, resident #7?s uniformed assessment instrument (UAI) dated 10-24-21 documented resident is fed by others. The individualized service plan (ISP) dated 10-24-21 did not document an approximate amount of time needed for meals to ensure resident?s needs are met.
Plan of Correction:	*Resident #7 has been discharged. *All other residents assessed as dependent in feeding on their UAI will have their Service Plans updated to include how much time is required by each to complete their meals to assure that their needs are being met. *This will be monitored during scheduled Core Check audits completed by the Directing Family Group and the results reported for Divisional Review Person Responsible: NCC/ACC or Designee/Dir./Divisional Leadership Target Completion Date: 6/30/2022 & ongoing
Standard #:	22VAC40-73-680-I
Description:	Based on document reviewed and staff interviewed, the facility failed to ensure the medication administration record (MAR) included all required information. Evidence: 1. Resident #2?s April 2022 medication administration record (MAR) did not include a diagnosis, condition, or specific indications for Eliquis, Prevagen, and Robaxin. 2. Staff #3 acknowledged the MAR did not include the diagnosis for the aforementioned resident?s medication on 4-7-22.
Plan of Correction:	*Resident #2 had their MAR updated to reflect the diagnosis, condition, or specific indications for Eliquis, Prevagen, and Robaxin. *The NCC/ACC will conduct a 100% audit of all MARs to assure that all resident medication orders also contain a diagnosis, condition, or specific indications. *All new medication orders will be reviewed by the NCC/ACC/LPN or RMA, prior to sending to the pharmacy, to assure that the orders also contain a diagnosis, condition, or specific indications *The NCC/ACC/LPN to conduct weekly medication audits, utilizing QuickMar, to assure that all ordered medications have a diagnosis, condition, or specific indications. * The findings from those audits will be reviewed weekly by the Directing Family Group and the results reported for Divisional Review.