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. 11, 2023 and Jan. 12, 2023

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 63.2 GENERAL PROVISIONS 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:

None.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/11/2023 from approximately 6:50 am to 4:15 pm and 1/12/2023 from approximately 7:35 am to 2:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 26 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 6 + selected sections of 2 additional resident records Number of staff records reviewed: 3 + selected sections of one additional staff record + 2 contract staff + 3 volunteers Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: Meals, medication and treatment administration observations, activities, resident-staff interactions, emergency food supplies, first aid kit, staff schedules, required postings, buildings and grounds, resident rooms, etc. Additional Comments/Discussion: Thank you for your assistance and cooperation during this inspection. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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. 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. 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 #:	22VAC40-73-520-I
Description:	Based upon documentation and interviews, the facility failed to ensure one of six residents individualized service plans (ISPs) included an individual activities schedule. Evidence: 1. On 1/11/2022, the licensing inspector (LI) interviewed the administrator who stated resident 5 was unable to participate in the posted activities. She stated he received individual activities, however, the individual activities schedule was not a part of the ISP. 2. On 1/11/2023, the LI interviewed the activities director who stated she conducted individual activities with resident 5 as he was unable to participate in the posted activities. 3. The ISP completed 10/2/2022 for resident 5 did not include the individual activities schedule.
Plan of Correction:	Individual activities schedule will be added to resident 5?s ISP. All staff trained to complete ISPs will include the Individual activities schedules for those residents physically or mentally unable to attend regular posted activities. The administrator will ensure this is done and is kept updated.