VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Legacy at North Augusta, Inc.
1410 A N. Augusta Street
Staunton, VA 24401
(540) 885-5454

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: May 8, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS

Technical Assistance:

Ensure at least two staff remain on the secured unit at all times and recommended all staff attend and in-service regarding the staffing requirements for a secured unit.

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 5/8/2023 from approximately 11:50 am to 2:00 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 4/28/2023 regarding allegations in the areas of: Additional Requirements For Facilities That Care For Adults With Serious Cognitive Impairments. Number of residents present at the facility at the beginning of the inspection: 83 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 0 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: Staffing and staff schedule Additional Comments/Discussion: Ensure all staff are knowledgeable of the staffing requirements for the secured unit and that all staff are clearly trained in what to do and who to contact if there are staffing concerns/problems. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint 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 Janice Knight, Licensing Inspector at (540) 430-9258 or by email at janice.knight@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1130-C
Complaint related:	Yes
Description:	Based upon interviews, the facility failed to ensure two staff remained on the secured unit at all times. Evidence: 1. The staff schedule for 4/27/2023 listed staff 2 and 3 working the secured unit from 7:00 pm to 7:00 am, staff 4 working first floor and also assigned as charge nurse from 6:45 pm to 7:15 am, and staff 7 (nurse) working third floor for assisted living (AL) from 6:45 pm to 7:15 am... 2. On 5/8/2023, the licensing inspector (LI) interviewed staff 2 who stated she worked the night shift (7:00 pm to 7:00 am) on the secured unit on 4/27/2023. She stated she was informed by the previous shift staff that staff 3 would be pulled to work the third floor of AL and staff 7 would be working the secured unit. Staff 2 stated she asked the staff to remain on the secured unit while she went to question staff 4 about the change. Staff 2 stated she told staff 4 that staff 7 was the nurse who was assigned to administer medications to all residents on the third floor ? assisted living and the secured unit and that she was supposed to be the one who floated between the units ? not the direct care aide. Staff 2 stated staff 4 told her they had a meeting and that was what they were supposed to do. 3. Staff 2 stated when staff 7 had to administer medications to the AL residents, especially during the morning hours, she was the only staff working on the secured unit. Staff 2 stated the charge nurse was not contacted to have a staff replace staff 7 when staff 7 left the secured unit. Staff 2 stated there was only one staff during those times. 4. On 5/8/2023, the LI interviewed staff 3 who stated he was assigned to work the third floor AL on 4/27/2023 from 7:00 pm to 7:00 am. 5. On 5/8/2023, the LI interviewed staff 4 who stated staff 2 and 7 were assigned to the secured unit and staff 4 was assigned to third floor A. Staff 4 stated if staff needed help they should have called and no staff communicated that they needed help. Staff 4 also stated the staffing for the secured unit was two aides and one nurse who administers medications for third floor AL and secured unit. 6. On 5/8/2023, the LI interviewed staff 1 and 6 and both stated staff were told that two aides remain on the secured unit at all times and the nurse floats between AL and the secured unit.
Plan of Correction:	Two direct care staff were on the schedule for 4/27/2023. At all times the secured unit maintains a minimum of two direct care staff. Education was provided to staff confirming staff cannot remove staff from the secured unit that will result in less than two on the unit. The administrator confirms the schedule daily for compliance.