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: Dec. 12, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

Paper towels in downstairs bathroom (had just been taken out) Stains on ceiling in bathroom upstairs Exhaust fan renovation, downstairs in room 1A/1B bathroom

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: 12-12-2023, 10:30 ? 12:45 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: 11 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Alex Poulter, Licensing Inspector at (804)662-9771 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-A
Description:	Based on record review, the facility failed to ensure all direct care staff shall attend at least 14 hours of training annually. Evidence: Training records for Staff #1 and Staff #2 were not seen in the records for any training completed in the last year, nor since their anniversary dates of hire. Staff #1 had one training (four-hour medication refresher course) dated 12-09-2022. Staff #1 confirmed onsite that no other training was able to be located.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-320-A
Description:	Based on record review and interview with staff, the facility failed to ensure the resident?s physical examination contained a description of the person?s reactions to any known allergies. Evidence: 1. Resident #3?s Physical Examination dated 4-26-2023 documented allergies to Folic Acid, Penicillin, Ultram, Codeine, Influenza vaccine whole; however, no reactions were listed. 2.Resident #4?s Physical Examination dated 2-03-2023 documented an allergy to Pravastatin; however, no reactions were listed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-B
Description:	Based on record review and interview with staff, the facility failed to ensure the designee had successfully completed the department-approved individualized service plan (ISP) training, provided by a licensed health care professional practicing within the scope of his profession, to develop a comprehensive ISP to meet the resident's service needs. Evidence: Resident #2?s ISP dated 9-27-2023 and Resident #3?s ISP dated 5-30-2023 was completed by Staff #1, who acknowledged she has not completed the required ISP training. Staff #1 did not have a certificate and was given information to completed ISP by licensing inspector via email.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-450-F
Description:	Based on record review and interview with staff, the facility failed to ensure the individualized service plan (ISP) was signed and dated by the licensee, administrator, or his designee, (i.e., the person who has developed the plan), and by the resident or his legal representative. Evidence: Resident #1 admitted 11-06-2023. Resident #1 had only one ISP in the file, undated, that did not specify whether it was the preliminary or comprehensive. The ISP on file did not have a signature or date in the staff nor resident lines of the ISP. Staff #1 confirmed onsite that the ISP was not signed or dated by any party.
Plan of Correction:	Not available online. Contact Inspector for more information.