Poplar Springs Hospital was cited during an on-site investigation completed by the Virginia Department of Behavioral Health and Developmental Services (DBHDS) for deficiencies related to therapy provided by unauthorized personnel, facility maintenance, building evacuations, and medication delivery. DBHDS cited Poplar Springs for allowing an employee to provide therapy to residents even though the employee was not eligible to do so. The DBHDS found that the employee’s Board of Health Professions letter “does not include a provision for Poplar Springs. Therefore Employee 9 is not eligible to provide therapy within this setting.” DBHDS also found maintenance and housekeeping deficiencies in the facility, including bathrooms in disrepair. DBHDS noted the following during its facility review: 1. Bathroom showers appear to be moldy and dirty. 2. Several shower curtains do not adequately cover the shower area to provide for adequate privacy. 3. Several bolts that hold the mirrors in the bathroom are rusty and in need to be replaced. 4. Several of the vents in the residents bathrooms and rooms are dusty and in need of being cleaned. 5. Some of the lights in the hall had what appeared to be dead bugs and are in need of being replaced. 6. The resident’s storage room was in disarray and needs to be organized. There were items stored within 18 inches of the ceiling which is noted to be a fire hazard. 7. There were some tiles in the roof of the hall area that had water stains and are in need of being replaced. The facility was also cited for improper evacuation of residents during a fire drill. During the inspection, a fire drill was conducted on the Girls RTC to simulate a fire in the blue room. DBHDS noticed that “the girls moved out of the room but were awaiting outside the door, and did not evacuate from outside area of the room.” Even though drills should incorporate evacuation from the building, DBHDS interviews with residents and staff revealed that “they do not evacuate the building during drills, they only have movement within the building behind identified fire doors.” DBHDS also determined that the facility failed to administer medications as prescribed. DBHDS found a case where Triamcinolone Acetonide cream was to be applied topically twice a day to treat a patient’s eczema, but there was no evidence that the evening doses were given on two consecutive days. In another case, DBHDS found that the patient’s “medication administration record (MAR) documents for January, February, and March had numerous blank spaces not indicating if the medications was given or not.” In the Corrective Action Plan, the provider agreed to revise policies to ensure all employees are licensed to provide therapy and receive the appropriate supervision. The facility also made plans to repair and/or replace the items found during the inspection. Lastly, the provider added additional actions to make sure that medications are documented and administered as prescribed.