VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Blacksburg Campus
3400 South Point Dr.
Blacksburg, VA 24060
(540) 317-3463

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Sept. 8, 2022

Complaint Related: Yes

Areas Reviewed:

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

Comments:

Type of inspection: Complaint Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/08/2022 9:45AM through 1:00PM. 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 07/29/2022 regarding allegations in the areas of: resident care and related services and personnel. The evidence gathered during the investigation did not support the allegations of non-compliance with standard(s) or law. However, violation(s) not related to the complaint but identified during the course of the investigation can 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 #:	22VAC40-73-450-D
Complaint related:	No
Description:	Based on resident record review, the facility failed to specify what hospice services were being provided on the individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 1, dated 11/18/2021 and updated 7/18/2022, shows that hospice services began 11/17/2021; however, the services to be provided were not specified.
Plan of Correction:	Resident no longer resides within the facility. An ISP audit will be conducted by the Administrator/DON/Designee, at random, monthly for 3 months and intermittently moving forward in order to ensure that hospice provided services are notated as required by VDSS standards.
Standard #:	22VAC40-73-450-E
Complaint related:	No
Description:	Based on resident record review, the facility failed to obtain some required signatures on the individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 1 was initially done on 11/18/2021 and there is no signature from the resident or the resident?s legal representative. This plan was updated on 1/26/2022, 1/27/2022, and 06/20/2022 and there are no signatures from the facility or the resident/legal representative. This plan was updated 7/18/2022 and there is no signature from the resident or legal representative.
Plan of Correction:	Resident no longer resides within the facility. An ISP audit will be conducted by the Administrator/DON/Designee, at random, monthly for 3 months and intermittently moving forward in order to ensure that required signatures are obtained as required by VDSS standards.
Standard #:	22VAC40-73-640-A
Complaint related:	No
Description:	Based on document review, the facility failed to implement their medication management plan regarding methods to ensure accurate counts of controlled substances whenever assigned medication administration staff changes. EVIDENCE: 1. Section 14.A. of the facility?s medication management plan states, ?During shift change, all narcotics, cards, bottles, sheets are counted and recorded by the oncoming and off-going medication persons. The oncoming and off-going both sign off on the accurate counts of all narcotics on the Narcotic Administration Record.? 2. Schedule 2 drugs are counted on a different form, the Narcotic Count Sheet. The Narcotic Count Sheets for August 2022 for Cart 3 show numerous omissions as noted below: 8/1/2022, no oncoming signatures at 3 pm or 11pm, no bottle count on 1st shift, no counts for 3rd shift; 8/4/2022, no oncoming signature at 3 pm, no counts for 1st shift; 8/5/2022, no oncoming signature at 3 pm, no off-going signature at 7 am; 8/6/2022, no oncoming signature at 7 am, no counts for 1st shift, no bottle counts for any shift; 8/7/2022, no off-going signature at 3 pm, no oncoming signature at 3 pm, no counts for 1st shift; 8/9/2022, no off-going or oncoming signatures at 3 pm, no counts for 1st shift; 8/12/2022, no bottle count for 1st shift; 8/15/2022, no counts entered for cards, pages, or bottles; 8/16/2022, no counts for bottles on 1st or 2nd shift; 8/17/2022, no off-going or oncoming signatures at 3 pm, no counts for 1st shift; 8/18/2022, no signatures at all for 2nd or 3rd shift, no counts at all; 8/19/2022, no signatures and no counts; 8/20/2022, no oncoming signature for 7 am, no page count for 1st shift; 8/21/2022, no oncoming signature for 3 pm, no off-going signature for 7 am, no counts for 2nd or 3rd shift; 8/22/2022, no signatures and no counts; 8/23/2022 no signatures for first shift and oncoming at 3 pm, no off-going signature for 7 am, no counts at all; 8/24/2022, no oncoming signature at 7 am, no counts for 1st or 2nd shift; 8/26/2022, no signatures for 3 pm; 8/27/2022, no signatures for 3 pm, no counts for 1st shift; 8/28/2022, no signatures for 3 pm, no counts for 1st shift; 8/29/2022, no counts at all, no signatures for off-going or oncoming at 11 pm, no signature for oncoming at 7 am; 8/30/2022, no signature for oncoming at 7 am, no off going signature for 7 am at end of day, no counts for 1st or 3rd shift; 8/31/2022, no oncoming signature at 1 am, no page counts.
Plan of Correction:	Resident no longer resides within the facility. A educational meeting was conducted on 9/8/22 with Medication Administration Staff. The subjects covered during the meeting were as follows: Medication Administration Guidelines, the Facility Medication Management Plan (including methods to ensure accurate counts of controlled substances whenever assigned Medication Administration Staff changes), and Documentation. A Controlled Substance Count audit to be conducted by the Administrator/DON/Designee, at random, weekly for 3 months and intermittently moving forward in order to ensure that accurate counts of controlled substances are documented as required by VDSS standards.
Standard #:	22VAC40-73-700-1
Complaint related:	No
Description:	Based on resident record review, the facility failed to obtain a complete oxygen order for a resident. EVIDENCE: The oxygen order for resident 1 lacks information regarding the source of the oxygen, for example: tank or concentrator.
Plan of Correction:	Resident no longer resides within the facility. A educational meeting was conducted on 9/8/22 with Medication Administration Staff. The subjects covered during the meeting were as follows: Medication Administration Guidelines, Medication Management Plan (including requirements for complete oxygen orders), and Documentation. A Physician?s Oxygen Order audit to be conducted by the DON/Designee, at random, monthly for 3 months and intermittently moving forward in order to ensure that oxygen orders contain information regarding the source of the oxygen per VDSS standards.