VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Stuarts Draft Christian Home
144 Patton Farm Road
Stuarts draft, VA 24477
(540) 932-3050

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Jan. 20, 2021 , Jan. 21, 2021 , Jan. 22, 2021 and Jan. 26, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS.

Technical Assistance:

Discussion occurred with the administrator on the following: 1) Even though the administrator reported there were no seriously cognitively or physically impaired residents who are unable to use the call bell, recommended the call bell log include the specific resident's name (instead of room number) and the staff name (instead of initials) - see 930.D.4. 2) Discussed and answered questions regarding 830.E - written copies of the facility's response to the resident council's recommendations to resolve problems/concerns must be given to the council prior to the next meeting - it does not state every resident; however, that is a good practice. 3) Even though there were no problems noted during any of the fire drill logs reviewed, the form did not include a section to document corrective actions taken to correct problems. Recommended this section be added to the model form being used to ensure the information is documented if problems were to occur.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 1/20/21 and concluded on 1/26/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 20. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident records, three staff records, activities calendars, menus, staff schedules, fire drills, medication administration records, physicians' orders, medication pharmacy reviews, dietitian's reviews, health care oversights, as well as other documents, to ensure documentation was complete. Selected sections of three resident, two contract staff and five staff records were also reviewed. A virtual inspection and tour were also conducted. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility

Violations:

Standard #:	22VAC40-73-1030-D
Description:	Based upon documentation and an interview, the facility failed to ensure one of three non-direct care staff completed the required dementia training. Evidence: 1) The training record for staff H (hired 9/4/20) indicated completion of only one hour of dementia training. 2) On 1/26/21, the LI interviewed the administrator who stated staff H had only completed one hour of dementia training.
Plan of Correction:	A representative from Relias has been contacted and will be conducting a virtual orientation with the administrator, executive director and assistant to the DON so Relias can be used efficiently and be better understood. The assistant to the DON will ensure dementia training is completed during orientation, including for non-direct care staff.
Standard #:	22VAC40-73-260-C
Description:	Based upon observations, documentation and an interview, the facility failed to ensure the posted list of staff with first aid (FA) and cardiopulmonary resuscitation (CPR) certifications was kept current. Evidence: 1) During the virtual tour on 1/21/21, the LI observed the posted list of staff with FA and CPR certifications did not include new staff that had been hired and completed the training. 2) Documentation on the posted list indicated the list was last updated on 10/2/20. 3) On 1/21/21, the LI interviewed the administrator who stated the posted list was not current.
Plan of Correction:	The administrator will ensure that all new staff are added to the posted CPR/FA list and that the list is updated with changes.
Standard #:	22VAC40-73-350-A
Description:	Based upon interviews, the facility failed to ensure continued registration with the state police in order to receive notifications of sex offenders within the zip code area of the facility. Evidence: On 1/22/21, the licensing inspector (LI) interviewed the business office manager (BOM) and the administrator. Both stated they were not receiving notifications from the state police and that after checking, they realized they had not completed the full process when the new BOM was hired and so the facility was no longer registered.
Plan of Correction:	The administrator is now registered to receive notifications of sex offenders within the zip code area of the facility.
Standard #:	22VAC40-73-640-A
Description:	Based upon observation and an interview, the facility failed to ensure one of approximately 20 medications reviewed were replaced prior to expiration. Evidence: 1) During the virtual tour on 1/21/21, the medication carts were checked and the LI observed a bottle of multivitamins for resident B (admitted 12/18/20) had an expiration date of April 2020. 2) On 1/21/21, the LI interviewed the administrator who stated several cart audits by different staff had been completed during that time period and all missed this bottle.
Plan of Correction:	Any medications brought to the facility will be checked for current expiration dates prior to being placed in the med cart. This will be done by the registered medication aide (RMA) on duty. The director of nursing (DON) will ensure regular audits of the med carts are performed.
Standard #:	22VAC40-73-750-C
Description:	Based upon an interview, the facility failed to ensure the only request for having different accommodations in a room was obtained in writing. Evidence: On 1/26/21, the LI interviewed the administrator regarding resident E having a recliner instead of a bed in the room. The administrator stated the information was on the individualized service plan; however, the resident's request was not obtained in writing.
Plan of Correction:	Any resident who has a special request for accommodations will put the specific request in writing. The administrator will ensure compliance with this standard.