VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Jan's Residential Home I
307 N. High Street
P. O. Box 666
Blackstone, VA 23824
(434) 298-0993

Current Inspector: Coy Stevenson (804) 972-4700

Inspection Date: June 25, 2020 and July 1, 2020

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 32.1 Reported by persons other than physicians 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.

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 June 25, 2020, and concluded on 07/01/2020. The assistant administrator was contacted by telephone to initiate the inspection. The assistant administrator reported that the current census was eight (8). The inspector emailed the assistant administrator a list of items required to complete the inspection. The inspector reviewed two (2) resident records, two (2) staff records, U.A.I.s, individualized service plans, physical examination records, tuberculosis screening evaluations, fall risk assessments, pharmacy reviews, health inspections, fire inspections, staff certifications, and staffing schedules submitted by the facility to ensure documentation was complete . Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Technical Assistance provided regarding the facility?s annual health inspection which was dated March 20, 2019.

Violations:

Standard #:	22VAC40-73-100-A
Description:	VIOLATION: Based upon the documents submitted during the remote inspection, the facility failed to have a written infection control program that implements all components of the CDC, OSHA, and the Assisted Living Facilities Standards guidelines. EVIDENCE: The facility submitted infection control policy which failed to have an exposure control plan for blood borne pathogens, documentation of screening and immunization offered to or declined by the employees for hepatitis B vaccine , or OSHA requirements for reporting workplace injuries or exposure to infection. The submitted infection control policy "N.O. 14" failed to have evidence of procedures for implementation of infection prevention measures by staff such as the use of personal protective equipment, or a policy that would address the use of standard precautions when addressing an infectious disease. The facility's infection control policy also failed to have procedures for handling/storing / transporting linens that would prevent the spread of infection. The submitted policy failed to provide specific procedures for the staff as it relates to room sanitation that would provide guidance in preventing the spread of infection or provide specific instruction for the use of cleaning/ disinfecting agents.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-100-C-5
Description:	VIOLATION: Based upon the record review, the facility failed to have a record of the annual retraining of the infection control policies as applicable to the employee's job description. Upon review of the remote inspection documents, the facility failed to provide evidence that each employee received annual retraining of the infection control policies as applicable to the employee's job description for employee #1 or employee #2.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-290-A
Description:	VIOLATION: Based upon the staff schedule submitted during the remote inspection, the facility failed to include the job classification of all staff working each shift with an indication of the identified in charge staff member for each shift. EVIDENCE: Five out five staff schedules that were submitted during the remote renewal inspection, ranging from January 26, 2020, unto June 07, 2020, failed to indicate the job classification of each staff member or identify which staff member would be in charge `during each assigned shift.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-550-G
Description:	VIOLATION : Based upon the documents submitted for the renewal inspection, the facility failed to ensure that the rights and responsibilities of each residents in the facility shall be reviewed annually. EVIDENCE: Upon request the facility failed to provide evidence of the most recent acknowledgement of the resident rights and responsibilities for resident #1 and resident #2 were reviewed annually. During the remote renewal inspection , the facility failed to fax the requested records identified by the licensing inspector. Instead, the facility faxed to the licensing inspector six additional resident records that failed to have the annually reviewed of the resident's rights and responsibilities.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-560-F
Description:	VIOLATION: Based upon the submitted remote inspection documents, the facility failed to make all records available for inspection. EVIDENCE: Upon request the facility failed to provide the MARS, physical examination forms, TB screenings, physician?s orders, UAIs, and ISPs for resident record #1 and resident record #2. During the remote inspection the licensing representative identified two specific records to review from the facility's census list. The facility provided additional resident records but failed to provide the requested records identified in the remote inspection.
Plan of Correction:	Not available online. Contact Inspector for more information.