VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Summit Square
501 Oak Avenue
Waynesboro, VA 22980
(540) 941-3100

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: June 30, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

None.

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: 6/30/2022 from approximately 1:20 pm to 4:30 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 4/1/2022 regarding allegations in the area of resident care. Number of residents present at the facility at the beginning of the inspection: 35 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 8 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can 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 #:	63.2-1720-C-1
Description:	Based upon record reviews and an interview, the facility failed to ensure two of the three staff records reviewed had verification on file that the employees had not been convicted of any barrier crimes since being employed. Evidence: 1. The most recent sworn statement on file for staff 2 (hired 5/12/2015) was signed as completed on 9/15/2019. 2. The most recent sworn statement on file for staff 3 (hired 4/27/2018) was signed as completed on 9/12/2019). 3. On 6/30/2022, the licensing inspector (LI) interviewed the administrator who stated these were the most current sworn statements on file.
Plan of Correction:	Sworn Disclosure Statements for Staff 2 and Staff 3 have been completed as of 07/01/2022. ? The Human Resources Director will conduct a full audit of Sworn Disclosure Statements for all employees by 07/13/2022. If any discrepancies are found, they will be corrected by 07/22/2022. ? Moving forward the Sworn Disclosure Statement will be completed annually as part of the employees? Annual Review process; their supervisor will ensure the document is signed before all documents are sent to Human Resources. The Human Resources Director, or designee, will conduct an audit at the beginning of each month to ensure compliance.