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 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: 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 09/07/2022 regarding allegations in the area of resident care and related services. An exit meeting will be conducted to review the inspection findings. 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 resident record review and document review, the facility failed to ensure to implement their medication management plan. EVIDENCE: The facility?s medication management plan provided during on-site inspection on 09/08/2022 indicated the following: ?5. Methods for verifying that medication orders have been accurately transcribed to the Electronic Medication Administration Record: B. The Pharmacy is responsible for transcribing orders to the Electronic Medication or Treatment Record at the time they are received from the Physician or Prescriber within 24 hours of receipt of the the [sic] New Order of Change in the Order. The DON/Nurse/MT is responsible for verifying accurate input of the new order or change in the order. The record for resident 1 contained a physician?s order, dated 09/02/2022, for the following medications due to the resident?s diagnosis of pneumonia: Doxycycine 100MG by mouth two times a day for seven days, Zithromax 250MG take as directed for seven days, and Culturelle two capsules by mouth every day for 14 days. The aforementioned medications were delivered to the facility on 09/02/2022; however, the administration of the three medications did not start until 09/06/2022. Interview with staff 2 confirmed this was accurate as the medications were not transcribed to the electronic medication administration record until 09/06/2022 therefore staff were unaware to administer the medications to the resident until 09/06/2022.
Plan of Correction:	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 methods to verify that medication orders have been accurately transcribed to the Electronic Medication Administration Record at the time that they are received from the Physician or Prescriber within 24 hours of receipt of the new or changed order.), and Documentation. Reeducation was provided to the Medication Administration Staff directly involved with the occurrence on or before 9/15/22. Regional Director of Resident Care/Designee performed Medication Pass Observations, at random, on 9/11/22 in order to verify accurate medication administration guidelines were followed. Regional Nursing Supervisor completed Medication Cart audits for accuracy by 9/14/22. DON/Designee will conduct an educational Medication Management meeting monthly for 3 months and intermittently moving forward in order to review the aforementioned topics as a method of ensuring requirements of VDSS standards are maintained.
Standard #:	22VAC40-73-650-B
Complaint related:	Yes
Description:	Based on resident record review, the facility failed to ensure a physician or other prescriber?s oral order for administering a medication included the route, dosage, and how often the medication is to be given to a resident. EVIDENCE: The record for resident 1 contained a physician?s order, dated 09/02/2022, for Zithromax 250MG take as directed for seven days. The order does not include the route, dosage, nor how often the medication is to be administered to the resident. Interview with staff 1 confirmed this is accurate.
Plan of Correction:	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 ensuring physician or other prescriber?s oral orders for administering a medication include the route, dosage, and how often the medication is to be given.), and Documentation. A clarification order was obtained on 9/9/22 to include the route and dosage for the Zithromax 250MG. DON/Designee will conduct an educational Medication Management meeting monthly for 3 months and intermittently moving forward in order to review the aforementioned topics as a method of ensuring requirements of VDSS standards are maintained.