VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Birch Gardens
12 Royal Drive
Staunton, VA 24401
(540) 886-5007

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Oct. 6, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Recommended scheduled II drug count sheets be checked at least weekly and narcotic count processes be observed on a regular basis for all registered medication aides/nurses.

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 10/6/2022 from approximately 1:45 pm to approximately 2:20 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 9/19/2022 regarding allegations in the areas of: Personnel and Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: Selected sections of 6 Number of staff records reviewed: Selected sections of 3 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Additional Comments/Discussion: None An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based upon interviews and documentation, the facility failed to ensure the facility?s medication management plan was implemented. Evidence: 1. On 9/17/2022 at 1:00 am, staff 1 administered an as needed (PRN) dose of morphine to resident 1. 2. On 9/17/2022 at 6:00 pm, staff 2 found an empty box with a pharmacy label for morphine with resident 1?s name on it setting on resident 1?s bedside table. 3. On 9/17/2022, staff 2 took the empty box to staff 3 who checked the medication cart and could not find the bottle of morphine. 4. On 9/17/2022, staff 3 notified staff 5 who coordinated a search for the medication; however, the medication was not found. 5. The narcotic count sheet for 9/17/2022 at the 6:00 am shift change was signed off by staff 1 and 5; the narcotic count sheet for the 2:00 pm shift change was signed off by staff 3 and staff 5. 6. On 10/4/2022, the licensing inspector (LI) interviewed staff 1 who stated, ?I did not count the liquid morphine. I always count the pill cards but do not always count the liquids.? 7. On 10/11/2022, the LI interviewed staff 5 who stated, ?I wasn?t told she had been given morphine. I don?t always count if they haven?t been given any ? sometimes I do and sometimes I don?t.? 8. On 10/11/2022, the LI interviewed staff 3 who stated, ?I?m not going to lie, staff 5 and I didn?t complete the count that day. We didn?t count all the medications as I got sidetracked and staff 5 went on to do something else.? 9. The facility?s medication management plan states on page 171 and 172: ?All medication maintained within the facility that fall under the DEAs Schedule of II ? IV will be: - Locked in the medication cart in a double lock box, the locks of which open with separate keys. - Will be counted by an RMA/nurse from the off going shift and one from the oncoming shift. This procedure will occur at the beginning and end of all shifts in the facility. - Keys to the medication cart will be maintained by the person(s) passing medications and only after a count of controlled substances has occurred will keys be passed to another RMA or nurse for any reason.
Plan of Correction:	All Registered Medication Aides were in-serviced on the facilities medication management plan. Each medication aide will have one medication pass observed by the wellness director with suggestions made to enhance and ensure compliance with the facilities medication management plan. The wellness director or designee will conduct biweekly audits of the registered medication aide to check for compliance to the medication management plan.
Standard #:	22VAC40-73-660-A-2
Description:	Based upon interviews, the facility failed to ensure one scheduled II medication was stored in a double locked area. Evidence: 1. On 9/17/2022 at 1:00 am, staff 1 administered an as needed (PRN) dose of morphine to resident 1. 2. On 9/17/2022 at 6:00 pm, staff 2 found an empty box with a pharmacy label for morphine with resident 1?s name on it setting on resident 1?s bedside table. 3. On 10/4/2022, LI interviewed staff 1 who stated, ?I went into her room and gave her the 0.25mg morphine as she asked for it. I gave it to her, put the cap back on the bottle, the syringe in the morphine box and I don?t recall whether I put the morphine in the box or not. I always put the syringe and bottle in the box.? 4. On 10/11/2022, the LI interviewed staff 3 who stated when she was notified about the empty box found in resident 1?s room she checked the medication carts and the morphine was not located.
Plan of Correction:	A one hundred percent audit has been conducted of all resident medications scheduled II to ensure they are all stored properly in a double locked area. Each registered medication aide has been in-serviced on the importance of following the protocol for keeping scheduled II medications under double lock. Each medication aide will have one medication pass observed to ensure they are following the process on double locking the scheduled II medications. The wellness director or designee will conduct biweekly audits and observations of the medication cart to ensure that all scheduled II medications are stored properly.