VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hope Haven
24532 Prince Edward Highway
Rice, VA 23966
(434) 392-9276

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 6, 2024

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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS 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 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

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: 05/06/2024 10:20AM until 3:57PM 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: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication cart audit, afternoon medication pass An exit meeting will be conducted to review the inspection findings. 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on staff record review and staff interview, the facility failed to ensure that at least two of the required hours of training shall focus on infection control and prevention. EVIDENCE: 1. The date of hire for staff person 2 is 03/01/2021. The record for staff person 2 did not contain documentation for the training year 03/01/2023 through 02/29/2024 that staff person 2 had at least two hours of training focusing on infection control and prevention. 2. Interview with staff person 4 confirmed that this is accurate.
Plan of Correction:	The Administrator and Director reviewed standard 22VAC40-210-F, the noted violation, and Hope Haven's infection control policy. The Administrator and Director will ensure that all new hire training will be done in orientation and a 2-hour refresher will be done annually. The Administrator and Director will conduct a monthly audit with Human Resources to make sure this is done and remains in compliance for training for employees.
Standard #:	22VAC40-73-270-1
Description:	Based on staff record review and staff interview, the facility failed to ensure that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents for assisted living facilities that accept, or have in care, residents who are or who may be aggressive. EVIDENCE: 1. The record for staff person 1, date of hire 08/09/2023, does not contain documentation that they had training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. 2. Interview with staff person 4 confirmed that this is accurate and that the facility does accept or have in care residents who are or who may be aggressive.
Plan of Correction:	The Administrator and Director reviewed standard 22VAC40-73-1.a., the noted violation at Hope Haven, the Administrator and Director will review all records to make sure all aggressive behavior training for staff is completed upon hire in orientation and a refresher course will be conducted annually. The Administrator and Director will review and conduct an audit on all training with Human Resources monthly.
Standard #:	22VAC40-73-580-A
Description:	Based on staff interview, the facility failed to ensure when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by annual reports from the Virginia Department of Health. EVIDENCE: During on-site inspection, evidence of an annual inspection by the Virginia Department of Health was unable to be produced. As of 05/09/2024, the licensing inspector (LI) was still not provided evidence of an annual inspection. Interview with staff person 3 confirmed that this is accurate.
Plan of Correction:	The Administrator and Director reviewed standard 22VAC40-73-580-A, the noted violation at Hope Haven for the Health Department. The Director contacted the Health Department to schedule the annual inspection in the future the Administrator and the Director would reach out to schedule 5 months ahead to get in date on the books for the inspections due to the Health Department being behind in scheduling. The administrator and Director will continue to monitor to make sure this is done promptly.
Standard #:	22VAC40-73-640-A
Description:	Based on facility plan review, staff record review, and staff interview, the facility failed to ensure to implement its medication management plan regarding methods to ensure an understanding of the responsibilities associated with medication management and identification of the medication aide or the person licensed to administer drugs responsible for routinely communicating issues or observations related to medication administration to the prescribing physician or other prescriber. EVIDENCE: 1. The facility?s medication management plan, revised 05/22/2022, indicates that each registered medication aide (RMA) is required to attend an annual medication administration refresher course (minimum of 4 hours) as required by noted standards and current medication management plan. 2. The record for staff person 2 contained documentation that the last medication management four-hour refresher course that staff person 2 completed was on 02/10/2023. Interview with staff person 4 confirmed that this is accurate. 3. The facility?s medication management plan, revised 05/22/2022, indicates that the facility administrator, assisted living facility coordinator, registered medication aides, and contracted healthcare oversight professional, if applicable, will be responsible for communicating issues or observations related to medication administration to appropriate physician or prescriber and that examples of issues or observations that are required to be communicated and documented are but are not limited to resident displaying loss of balance or increased falls/injuries related to balance, decrease in appetite (food/water intake), change in mental status or routine behaviors, or changes in weight or other vitals. 4. The record for resident 3 contains a physician?s order, dated 11/14/2023, for latanoprost 0.005% eye drops one drop in both eyes every evening. The back side of the page of resident 3?s March 2024 medication administration record (MAR) contains documentation for 03/01/2024 through 03/07/2024 and 03/09/2024 through 03/21/2024 that the resident refused latanoprost 0.005% eye drops on these days at 8:00PM. In addition, the back side of the MAR also includes instructions that staff are to circle their initials when medication or treatment is refused. The March 2024 MAR contains RMA circled initials daily at 8:00PM from 03/01/2024 through 03/31/2024 for latanoprost 0.005% eye drops. The back side of the page for resident 3?s April 2024 MAR contains documentation for 04/02/2024 through 04/11/2024 and 04/13/2024 through 04/21/2024 that the resident refused latanoprost 0.005% eye drops on these days at 8:00PM. In addition, the back side of the MAR also includes instructions that staff are to circle their initials when medication or treatment is refused. The April 2024 MAR contains RMA circled initials daily at 8:00PM from 04/02/2024 through 04/30/2024 for latanoprost 0.005% eye drops. The back side of the page of resident 3?s May 2024 medication administration record (MAR) contains documentation for 05/05/2024 that the resident refused latanoprost 0.005% eye drops on this day at 8:00PM and the RMA initialed and circled their initials that the resident had refused the eye drops. Interview with staff person 1 revealed that they also did not administer the eye drops to resident 3 on 05/01/2024 and 05/03/2024. 5. Staff persons 1 and 4 both acknowledged to the LI that when a resident continues to refuse a medication that it should be reported to the resident?s appropriate physician or prescriber as indicted in the facility?s medication management plan as an observation or an issue of medication administration and that the resident continuing to refuse the latanoprost 0.005% eye drops has not been reported to the appropriate physician or prescriber for the resident. Staff persons 1 and 4 and the LI noted that there were two unopened bottles of latanoprost 0.005% eye drops in the medication cart for resident 3.
Plan of Correction:	The Administrator and the Director reviewed policy 22VAC40-73-640A, the noted violation, and Hope Haven's Medication Management Plan. The Administrator and the Director reviewed the RMA records to make sure that each of the RMA had their 4-hour refresher course. The refresher course has been scheduled and the RMA will attend the required training to stay in compliance. The Administrator/Director will conduct a monthly audit on training with Human Resources to make sure all training is posted 30 days in advance. The Administrator and Director reviewed standard 22VAC40-73-640-A, the noted violation, and Hope Haven?s Medication Management Policy the Administrator and Director reviewed all MARs to ensure that any residents haven't refused or if they have refused their medications to make sure it was noted, that and the physician will be notified of the refusal. The resident has an appointment scheduled to see if another medication can be taken at this time to see if there is medication that is needed. All RMAs received verbal supervision regarding the above-noted standards and policies and a refresher course is scheduled for all RMAs. The Administrator/Director will conduct weekly audits of all medications and the Administrator will conduct monthly audits with the Health Care Oversight Nurse to ensure that the RMAs are following the medication management policy and compliance.
Standard #:	22VAC40-73-950-E
Description:	Based on staff interview, the facility failed to ensure that a review of the facility?s emergency preparedness and response plan was completed semi-annually with staff and residents. EVIDENCE: 1. Interview with the licensing inspector (LI) and staff person 3 during on-site inspection on 05/06/2024 revealed that the last semi-annual review of the facility?s emergency preparedness and response plan occurred with residents and staff in January 2023. 2. No documentation was available for review on 05/06/2024 to show that a semi-annual review has been completed since that time.
Plan of Correction:	The Administrator and Director reviewed standard 22VAC40-73-950E, the noted violation, and Hope Haven's Emergency Preparedness Plan. The Administrator and Director reviewed the facility emergency preparedness plan at the next QA meeting which is on 05/29/2024 for review. The Administrator and Director will make sure that the QA plan is reviewed every 6 months in the months of May and November, in-service will be conducted, and make sure that the individuals and the staff sign off on the forms to stay in compliance with emergency preparedness.
Standard #:	22VAC40-73-990-B
Description:	Based on staff interview, the facility failed to ensure the facility?s written plan for resident emergencies shall be reviewed by the facility at least every six months with all staff and documentation of the review shall be signed and dated by each staff person. EVIDENCE: 1. Interview with the licensing inspector (LI) and staff person 3 during on-site inspection on 05/06/2024 revealed that the last semi-annual review of the facility?s plan for resident emergencies occurred in February 2023. 2. No documentation was available for review on 05/06/2024 to show that a semi-annual review has been completed since that time.
Plan of Correction:	The Administrator and Director reviewed the standard 22VAC40-73-990-B, the violation noted Hope Haven, The Administrator and Director will review with the resident the importance of what to do in case of an emergency and drills will be done so that each resident will understand what to do in case of an emergency. The Administrator and Director will conduct an audit every 6 months to make sure there is documentation done so that we can remain in compliance.