VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Glebe
200 The Glebe Boulevard
Daleville, VA 24083
(540) 591-2100

Current Inspector: Angela Marie Swink (276) 623-6575

Inspection Date: April 10, 2024

Complaint Related: No

Areas Reviewed:

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

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: 4/10/2024 08:00am to 03:00pm 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 3/21/2024 regarding allegations in the area(s) of: Personnel and Resident Care and Related Services Number of residents present at the facility at the beginning of the inspection: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: 1 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the self-report; area(s) of non-compliance with standard(s) or law were: Personnel A violation notice was 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 A Marie Swink, Licensing Inspector at 276-635-6575 or by email at angela.swink@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-130-A
Description:	Based on document review and staff interview, the facility failed to ensure that all staff who are mandated reporters under ? 63.2-1606 of the Code of Virginia report suspected abuse or neglect of residents in accordance with that section. EVIDENCE: 1.The licensing inspector (LI) received a self-report, from the facility, of verbal abuse allegations on resident 1 on 3/21/2024 by a staff member. The final report was received on 3/26/2024 however neither report had documentation on the local Adult Protective Services agency being notified. 2. During an interview conducted with one LI and staff person 1 on 4/10/2024, it was confirmed that these allegations of suspected abuse were brought to their attention on 3/21/2024, however, staff 1, who completed the self ? report, did not report these allegations of suspected abuse to their local Adult Protective Services Agency as required by ?63.2-1606 of the Code of Virginia.
Plan of Correction:	Plan of Correction: This plan of correction is the written allegation of compliance for the deficiencies cited. The submission of this plan of correction is not an admission that a deficiency exists or that one was incorrectly cited. This plan of correction is submitted to meet the requirements established by state regulations. On 4/10/2024 it was determined that the Department of Social Services was notified on 3/21/2024 of an allegation of verbal abuse. A final report was sent to the Department of Social Services on 3/26/2024. The Director of Health Services was unable to provide documentation that Adult Protective Services had received notification. On 4/10/2024 The Director of Health Services faxed a copy of the final report to Adult Protective services and the local ombudsman for review. Confirmation not received. Re-faxed copy of final report on 4/11/2024. Confirmation received. On 4/10/2024 the Director of Health Servies was re-educated on the importance of notification to the Adult Protective Services for any allegations involving Abuse and/or Neglect by A Marie Swink Licensing Inspector, Division of Licensing Programs. The community will ensure compliance by 4/12/2024 through audits weekly by reviewing the confirmation reports to ensure all regulatory entities have been notified Weekly x 4 weeks then monthly x 3 months and report findings during the quarterly QA meeting.