VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Village at Orchard Ridge
400 Clocktower Ridge Drive
Winchester, VA 22603
(540) 431-2800

Current Inspector: Jill James (540) 418-2631

Inspection Date: March 15, 2023

Complaint Related: No

Areas Reviewed:

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

Technical Assistance:

Recommended having staggered times for shift report for nurses and certified nursing assistants.

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: 3/15/2023 from approximately 11:45 am to 4:15 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 3/14/2023 regarding allegations in the area of: Resident Care and Related Services. Number of residents present at the facility at the beginning of the inspection: 14 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: 2 (outside agency private duty personnel) Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 6 Observations by licensing inspector: Mealtime and resident and staff interactions Additional Comments/Discussion: Discussed additional interventions and changes to implement. 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 #:	22VAC40-73-220-A
Description:	Based upon documentation and interviews, the facility failed to ensure companion services were included on one of one individualized service plan (ISP) and that documentation was maintained on the care provided by the two private duty personnel (PDP). Evidence: 1. The ISP (updated 12/28/2022) for resident 1 did not include the private duty services (PDS) provided. 2. On 3/15/2023, the licensing inspector (LI) interviewed staff 2 who stated the PDS were not listed on resident 1?s ISP. 3. The notebook for documenting PDS for resident 1 did not include any documentation for 1/28/2023 - 1/29/2023, 2/2/2023 ? 2/5/2023, 2/7/2023 ? 2/8/2023, 2/10/2023, 2/15/2023 ? 2/19/2023, 2/21/2023 ? 2/24/2023, 2/26/2023 ? 2/28/2023, 3/2/2023 ? 3/13/2023. 4. On 3/15/2023, the LI interviewed staff 1 and 2 and both stated the PDS provided were not documented daily, as the services were provided.
Plan of Correction:	The ISP for resident 1 was immediately corrected by the Director of Nursing to include care companion services. As soon as care companion services are implemented, the Registered Nurse (RN) Care Coach will assure it is included in the resident?s ISP. The RN Care Coach or designees will adjust the ISP as any changes occur, including changes with the care companion service hours. The care companion was notified and made aware that documentation needs to be completed at the end of the scheduled shift. The nurse or certified nursing assistant (CNA) will assure the care companion has completed documentation prior to leaving at the end of the scheduled shift. The RN Care Coach will do a weekly visual audit to assure care companion documentation has been completed throughout the week.