VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Runk & Pratt of Forest
208 Gristmill Drive
Forest, VA 24551
(434) 385-0297

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Aug. 17, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 08/17/2022 10:00AM through 11:15AM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 06/28/2022 regarding allegations in the area of: resident care and related service in regards to medication management. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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
Complaint related:	Yes
Description:	Based on facility document review, the facility failed to ensure to implement their medication management plan. EVIDENCE: 1. The facility?s medication management plan, revised 02/2021, states the following for 640.3 (Methods to prevent the use of outdated, damaged or contaminated medications) and 640.11 (A plan for proper disposal of medication): Medications have been discontinued or found to be contaminated, damaged, and/or outdated should be disposed of properly. Schedule II medications will be of disposed of in the biohazard sharps container by (2) RMAs or LPNs. All Schedule II medications: a. labels removed and placed in trash/shredder box b. Medication is removed from bubble card or bottle and disposed of in sharps container c. Destruction Log require two authorized staff signatures. Staff 2 also indicated that controlled medications are also sometimes sent back to the prescribing pharmacy and require two authorized staff signatures. 2. The document ?Prescription returned to pharmacy? for resident 1, which is used by the facility when medications are returned to the pharmacy, indicates that Morphine was returned to the pharmacy on 09/18/2021 and 10 tablets of Lorazepam were returned to the pharmacy on 10/01/2021 by staff 1. The aforementioned document only contained the signature of staff 1. 3. The document ?Controlled Drug Record? for Morphine for resident 2 indicated by staff 1 that the medication expired on 01/08/2022 and only contains staff 1?s signature for the destruction. 4. Two documents ?Controlled Drug Record? contained the written statement by staff 1 ?Deceased destroyed 1-1-22? for resident 3 for the following medications: Fentanyl patch, Lorazepam, and two containers of Morphine Sulfate. The two documents only contained staff 1?s signature for the destruction. 5. The document ?Controlled Drug Record? for Morphine for resident 4 indicates that the medication expired on 01/11/2022 and only contains staff 1?s signature for the destruction. 6. The document ?Controlled Drug Report? for resident 5?s Gabapentin contained documentation and staff 1?s signature that staff 1 wasted a single dose of the medication on 01/16/2022; however, staff 1 did not waste this medication in the presence of another staff member. Staff 2 confirmed this information was accurate. 7. Two documents ?Controlled Drug Record? contained the written statement by staff 1 ?Deceased 1-10-22? for resident 6 for the following medications: Morphine and Lorazepam. The two documents only contained staff 1?s signature for the destruction. 8. Two documents ?Controlled Drug Record? for resident 7 for the medications Hydrocodone and Lorazepam contained the signature of staff 2 dated 01/04/2022. Staff 2 informed Collateral 1 that she made an error on both of the aforementioned Narcotic logs as they were wasted on 01/14/2022 instead of 01/04/2022 due to resident 7 passing away. Staff 2 stated she wasted the narcotics with staff 1; however, staff 1 did not sign the two aforementioned narcotic logs. 9. The document ?Controlled Drug Record? for resident 9?s Morphine contained the statement ?returned 9-18-21 overstock?. Staff 2 informed Collateral 1 that the statement was written by staff 1 and that staff 1 did not sign the record nor did staff 1 have a witness confirm the morphine was being sent back to the pharmacy. 10. The document ?Controlled Drug Record? for resident 10?s Tramadol contained the signature of staff 2, dated 01/04/2022. Staff 2 informed Collateral 1 that the actual date was 01/14/2022 and that it should have also contained the signature of staff 1 as staff 1 and 2 destroyed the aforementioned medication together. (see attached)
Plan of Correction:	Registered medication aides/nurse have been trained on the proper medication polices and procedures. Training includes proper handling of controlled medications which includes proper handling of controlled medications, proper disposal of/proper returns to pharmacy for disposal including two authorized staff signatures.