VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Elms of Lynchburg
2249 Murrell Road
Lynchburg, VA 24501
(434) 846-3325

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 15, 2024 and May 16, 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: 05/15/2024 8:00AM until 5:00PM & 05/16/2024 8:30AM until 11:00AM 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: 30 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 4 Observations by licensing inspector: morning medication administration, breakfast, medication cart audits 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 #:	22VAC40-73-325-C
Description:	Based on resident record review, the facility failed to ensure should a resident who meets the criteria for assisted living care fall, the facility must show documentation of an analysis of the circumstances of the fall and interventions that were initiated to prevent or reduce risk of subsequent falls. EVIDENCE: 1. The uniform assessment instrument (UAI) for resident 1, dated 04/06/2024, indicates that the resident is assisted living level of care. 2. The record for resident 1 contains a fall risk intervention care plan, dated 04/11/2024 at 8:34AM, that indicates the resident had a fall on 04/10/2024 at 6:10PM with injury in his room; however, the document does not contain documentation of any interventions that were initiated to prevent or reduce risk of subsequent falls. 3. The UAI for resident 2, dated 04/29/2023, indicates that the resident is assisted living level of care. 4. The record for resident 2 contains a fall risk intervention care plan, dated 03/18/2024 at 1:03PM, that indicates the resident had a fall on 03/17/2024 at 5:53PM without injury in their room; however, the document does not contain documentation of any interventions that were initiated to prevent or reduce risk of subsequent falls.
Plan of Correction:	22VAC40-73-325-C Facility will ensure all fall interventions are documented in a timely manner. Initiated Date: 6/3/2024 Completion Date: 7/29/2024; ongoing The Executive Director, Director of Nursing, Resident Care Manager, and/or Licensed Designee shall regularly monitor falls and interventions by holding a Clinical Risk Meeting twice a month. The Clinical Risk Meeting will include a section regarding falls documentation and intervention compliance. The Director of Nursing, Resident Care Manager, and/or Licensed Designee shall ensure that all information is kept up to date and valid. This Clinical Risk Meeting(s) will be continuous with no end date for ongoing monitoring. Audit Document: Risk Meeting Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Licensed Designee.
Standard #:	22VAC40-73-440-A
Description:	Based on resident record review and staff interview, the facility failed to ensure the uniform assessment instrument (UAI) shall be completed at least annually. EVIDENCE: The most recent UAI in the record for resident 2 during on-site inspection was dated 04/29/2023. Interview with staff person 12 confirmed that this is accurate and that the resident?s UAI has not been updated by the facility.
Plan of Correction:	22VAC40-73-440-A Facility will ensure all resident?s uniform assessment instrument (UAI) was completed at least annually. Initiated Date: 6/3/2024 Completion Date: 7/29/2024 The Director of Nursing and Resident Care Manager will audit all existing resident charts. The Director of Nursing and Resident Care Manager will implement a monitoring/audit system for all residents in the community for UAI updating and/or renewal. This audit will be carried out for 8 weeks with a minimal of 5 residents? charts being audited per week. Audit Document: Audit: Chart Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Licensed Designee.
Standard #:	22VAC40-73-450-E
Description:	Based on resident record review, the facility failed to ensure that the individualized service plan (ISP) shall be signed and dated by the resident or his legal representative. EVIDENCE: The ISP in the record for resident 3, dated 07/25/2023 & 07/26/2023, is not signed and dated by the resident or their legal representative.
Plan of Correction:	22VAC40-73-450-E Facility will ensure all resident?s comprehensive individualized service plans (ISP) are reviewed and updated at least once every 12 months. Initiated Date: 6/3/2024 Completion Date: 7/29/2024; ongoing The Director of Nursing and Resident Care Manager will audit all existing resident charts. The Director of Nursing will implement a monitoring/audit system for all residents in the community for ISP updating and/or renewal. This audit will be carried out for 8 weeks with a minimal of 5 residents? charts being audited per week. Audit Document: Audit: Chart Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-73-560-E
Description:	Based on resident record review and staff interview, the facility failed to ensure all resident records shall be kept current and retained at the facility. EVIDENCE: During on-site inspection the following signed physician?s orders were not available in the record for resident 4: divalroex 250MG capsule by mouth twice daily for behaviors, quetiapine 25MG tablet by mouth twice daily as needed for agitation, and quetiapine 75MG (take 1 and ? tablets by mouth twice daily for anxiety/mood) and in the record for resident 5: Selsun blue balanced treatment topical shampoo. Interview with staff person 1 revealed that the aforementioned orders had to be faxed to the facility during on-site inspection.
Plan of Correction:	22VAC40-73-560-E Facility will ensure all residents charts are reviewed, updated, signed by physician, have an appropriate diagnosis and dosage, and kept current regarding physician orders and pharmacy recommendations. Initiated Date: 6/3/2024 Completion Date: 7/29/2024 The Director of Nursing and Resident Care Manager will audit all existing resident charts to ensure all orders are current and accurate. The Director of Nursing and Resident Care Manager will implement a monitoring/audit system for all residents in the community. This audit will be carried out for 8 weeks with a minimal of 5 residents? charts being audited per week. After 8 weeks, Director of Nursing will be required to audit 2 residents? charts per week for accuracy. Audit Document: Audit: Chart Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee ? audit tool will be turned in weekly.
Standard #:	22VAC40-73-650-B
Description:	Based on resident record review, the facility failed to ensure physician or other prescriber orders, both written and oral, for administration of all prescription and over-the-counter medications and dietary supplements shall identify the diagnosis, condition, or specific instructions for administering each drug. EVIDENCE: 1. The record for resident 9 contains physician?s orders, dated 01/17/2024, for omeprazole 40MG, ferrous sulfate 325MG, and folic acid 1MG and a physician?s order, dated 01/24/2024, for Seroquel 25MG, that do not contain the diagnosis, condition, or specific instructions for administering the aforementioned medications. 2. The record for resident 10 contains physician?s order, dated 02/05/2024, for ascorbic acid 500MG, cholecalciferol 50MCG, cyanocobalamin 1000MCG, folic acid 0.4MG, hydrochlorothiazide 25MG, losartan 50MG, and quetiapine 25MG and an additional physician?s order, dated 02/23/2024, increase Seroquel 25MG, that do not include the diagnosis, condition, or specific instructions for administering the aforementioned medications.
Plan of Correction:	22VAC40-73-650-B Facility will ensure all residents charts are reviewed, updated, signed by physician, have an appropriate diagnosis and dosage, and kept current regarding physician orders and pharmacy recommendations. Initiated Date: 6/3/2024 Completion Date: 7/29/2024 The Director of Nursing and Resident Care Manager will audit all existing resident charts to ensure all orders are current and accurate. The Director of Nursing and Resident Care Manager will implement a monitoring/audit system for all residents in the community. This audit will be carried out for 8 weeks with a minimal of 5 residents? charts being audited per week. After 8 weeks, Director of Nursing will be required to audit 2 residents? charts per week for accuracy. Audit Document: Audit: Chart Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee ? audit tool will be turned in weekly.
Standard #:	22VAC40-73-650-F
Description:	Based on resident record review and staff interview, the facility failed to ensure whenever a resident is admitted to a hospital for treatment of any condition, the facility shall obtain new orders for all medications and treatments prior to or at the time of the resident?s return to the facility and the facility shall ensure that the primary physician is aware of all medication orders and has documented any contact with the physician regarding the new orders. EVIDENCE: The record for resident 3 contains staff documentation that the resident was sent to the hospital on 04/08/2024 due to shortness of breath. The resident?s record contains an order reconciliation report from the hospital, dated 04/15/2024, of the resident?s medications; however, there is no documentation that the resident?s primary physician was made aware of all medication orders or that any contact was made with the resident?s primary physician regarding the new orders. Interview with staff person 1 confirmed that this is accurate.
Plan of Correction:	22VAC40-73-650-F Facility will ensure all residents charts are reviewed, updated, signed by physician, have an appropriate diagnosis and dosage, and kept current regarding physician orders and pharmacy recommendations. Initiated Date: 6/3/2024 Completion Date: 7/29/2024 The Director of Nursing and Resident Care Manager will audit all existing resident charts to ensure all orders are current and accurate. The Director of Nursing and Resident Care Manager will implement a monitoring/audit system for all residents in the community. This audit will be carried out for 8 weeks with a minimal of 5 residents? charts being audited per week. After 8 weeks, Director of Nursing will be required to audit 2 residents? charts per week for accuracy. Audit Document: Audit: Chart Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee ? audit tool will be turned in weekly.
Standard #:	22VAC40-73-680-D
Description:	Based on resident record review and staff interview, the facility failed to ensure that medications shall be administered in accordance with the physician?s or other prescriber's instructions. EVIDENCE: 1. The April and May 2024 medication administration records (MARs) for resident 2 indicates that the resident is prescribed lispro insulin for type II diabetes twice daily at 7:00AM and 4:00PM, ordered 03/22/2024, and that the resident?s blood sugar is to be checked twice daily before breakfast and dinner and inject insulin subcutaneously per the following sliding scale: blood sugar less than 200 ? administer no insulin; blood sugar 200-350 ? administer 2 units of lispro; and blood sugar over 350 ? administer 3 units of lispro. The April 2024 MAR for the resident does not include documentation of what the resident?s blood sugar was at 4:00PM on 04/01/2024, 04/02/2024, 04/03/2024, 04/05/2024, 04/06/2024, 04/07/2024, 04/08/2024, 04/09/2024, 04/10/2024, 04/11/2024, 04/12/2024, and 04/16/2024 through 04/30/2024. The May 2024 MAR for the resident does not include documentation of what the resident?s blood sugar was at 4:00PM on 05/01/2024 through 05/14/2024. The April and May 2024 MARs also do not include documentation of how many units of lispro was administered to the resident or if the resident was supposed to be administered lispro based on what their blood sugar was, daily at 7:00AM and 4:00PM during both months. 2. The record for resident 9 contains a signed physician?s order, dated 05/03/2024, for Keflex 500MG every 8 hours for 10 days for cellulitis of left heel/foot and a signed physician?s order, dated 05/07/2024, for Keflex 500MG every 8 hours for cellulitis of left foot ?#4 caps?. The May 2024 MAR indicates that Keflex was not administered to the resident on 05/05/2024 at 11:00PM, 05/07/2024 at 11:00PM, and 05/08/2024 at 7:00AM, 3:00PM, and 11:00PM and the start date for the medication was 05/03/2024 and the end date was 05/13/2024. The May 2024 MAR for resident 9 indicates that the resident was only administered 22 doses of Keflex between 05/05/2024 through 05/13/2024. Interview with staff person 2 during on-site inspection on 05/15/2024 indicated that staff were no longer administering the medication to the resident even though the bottle that contained the resident?s Keflex still contained multiple capsules of Keflex. During on-site inspection, it was determined from Collateral 1 that 6 Keflex capsules were sent to the facility on 05/03/2024 and 24 Keflex capsules were sent to the facility on 05/09/2024. 3. The record for resident 10 contains a signed physician?s order, dated 02/05/2024, for seroquel 25MG take 0.5 tablet (17.5MG) two times a day and a signed physician?s order, dated 02/23/2024, to increase the resident?s prescribed seroquel to 25MG two times a day. The February 2024 medication administration record (MAR) for resident 10 contains documentation that the resident received a seroquel 17.5MG tablet and a Seroquel 25MG tablet at 9:00AM and 9:00PM on 02/25/2024, 02/26/2024 and at 9:00AM on 02/27/2024. This was also noted by staff person 1.
Plan of Correction:	22VAC40-73-680-D Facility will ensure adequate administration of medication in compliance with signed physician orders. Initiated Date: 6/3/2024 Completion Date: 7/29/2024 The Director of Nursing and Resident Care Manager will conduct medication pass observations with RMAs responsible for medication administration over the next 8 weeks to validate that they are administering medications in accordance with physician orders. If incorrect practice is observed, on-the-spot training will be provided and additional observations will be conducted to validate correct practice. The Director of Nursing/RN will provide an RMA Refresher training for medication aides regarding administering medications in accordance with physician orders. Audit Document: Medication Administration Orientation and Observation Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-73-680-I
Description:	Based on resident record review and staff interview, the facility failed to ensure the medication administration record (MAR) included the dosage. EVIDENCE: 1. The record for resident 3 contains a physician?s order, dated 12/15/2023, for lantus insulin 5 units with scale of the following: if blood sugar is less than 150 ? no extra units of insulin; blood sugar 151-200 ? give extra 1 unit; blood sugar 201-250 ? give extra 2 units; blood sugar 251-300 ? give extra 3 units; blood sugar 301-350 ? give extra 4 units; blood sugar 351-400 ? give extra 5 units and if blood sugar is greater than 400 give extra 6 units. The April and May 2024 MARs for the resident indicate that lantus is administered to the resident daily at 7:45AM, 11:45AM and 4:45PM. 2. The April 2024 MAR for the resident, dated 04/01/2024 through 04/08/2024 at 11:45AM and 04/15/2024 at 11:45AM through 04/30/2024 and the May 2024 MAR, dated 05/01/2024 through 05/15/2024 at 11:45AM, do not include documentation of how many units of lantus were administered to the resident. This was also noted by staff person 1.
Plan of Correction:	22VAC40-73-680-I Facility will ensure all residents charts are reviewed, updated, signed by physician, have an appropriate diagnosis and dosage, and kept current regarding physician orders and pharmacy recommendations. Initiated Date: 6/3/2024 Completion Date: 7/29/2024 The Director of Nursing and Resident Care Manager will audit all existing resident charts to ensure all orders are current and accurate. The Director of Nursing and Resident Care Manager will implement a monitoring/audit system for all residents in the community. This audit will be carried out for 8 weeks with a minimal of 5 residents? charts being audited per week. After 8 weeks, Director of Nursing will be required to audit 2 residents? charts per week for accuracy. Audit Document: Audit: Chart Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee ? audit tool will be turned in weekly.
Standard #:	22VAC40-73-860-I
Description:	Based on observations of the facility physical plant, the facility failed to ensure that cleaning supplies and other hazardous materials were stored in a locked area. EVIDENCE: At approximately 9:42AM, the door to room 204 was unlocked and contained a spray bottle of LA?s Totally Awesome all-purpose concentrated cleaner that was sitting on top of two containers of paint.
Plan of Correction:	22VAC40-73-860-I Facility will ensure cleanliness of facility and its structure. Initiated Date: 6/3/2024 Completion Date: 7/17/2024; ongoing The Maintenance Tech and Housekeeping staff will begin deep cleaning of all resident?s rooms and bathrooms over the next 2 weeks, ensuring that all resident?s rooms and bathrooms are free from chemicals and/or debris. The Executive Director will provide all department managers with an assigned Resident Room Walk-through check list. All residents? rooms will be inspected weekly over the next 8 weeks for cleanliness, compliance, and safety. Audit Document: Room Rounds Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-73-870-A
Description:	Based on observation during a walkthrough of the facility, the facility failed to ensure the interior of all buildings shall be maintained in good repair and kept clean and free of rubbish. EVIDENCE: At approximately 9:39AM, it was noted by the licensing inspector (LI) in the front entrance of the facility from the lobby area there is a small hole in the ceiling with discoloration around the hole in the ceiling and a trash can had been placed underneath the hole along with a caution wet floor sign because the ceiling had been leaking. It was verified with staff that the ceiling has been leaking from this hole. At approximately 9:42AM, a hole in the ceiling above the window and near the air vent in room 204 was observed. Pieces of the ceiling and insulation were on the floor underneath of the hole in the ceiling. At approximately 9:45AM on the back right hallway near the exit of the facility?s safe, secure unit, the LI noted a line of discoloration on the ceiling outside of resident rooms.
Plan of Correction:	22VAC40-73-870-A The Executive has reached out to facility?s corporation/owner(s) for assistance regarding roof repairs. Initiated Date: 5/29/2024 Completion Date: TBD Facility Maintenance Tech and Divisional Maintenance team will begin ceiling repairs once roof repairs have been successfully completed. Divisional Maintenance Director has begun obtaining quotes for roof repair. Executive Director will be notified of repair begin date and ETA for completion once a bid has been selected. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-73-870-E
Description:	Based on observation during a walkthrough of the facility, the facility failed to ensure all furnishings, fixtures, and equipment, including showers, shall be kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard. EVIDENCE: At approximately 8:18AM the licensing inspector (LI) noted a dark, black substance underneath the cover of the shower?s drain in resident 5?s bathroom. At approximately 8:21AM the LI noted a dark, black substance underneath the drain cover in the shower in resident 6?s bathroom. At approximately 8:31AM the LI noted a dark, black substance underneath the drain cover in the shower in resident 7?s bathroom. At approximately 8:38AM the LI noted a dark, black substance underneath the drain cover in the shower in resident 8?s bathroom.
Plan of Correction:	22VAC40-73-870-E Facility will ensure cleanliness of facility and its structure. Initiated Date: 6/3/2024 Completion Date: 7/17/2024; ongoing The Maintenance Tech and Housekeeping staff will begin deep cleaning of all resident?s rooms and bathrooms over the next 2 weeks, ensuring that all resident?s rooms and bathrooms are free from chemicals and/or debris. The Executive Director will provide all department managers with an assigned Resident Room Walk-through check list. All residents? rooms will be inspected weekly over the next 8 weeks for cleanliness, compliance, and safety. Audit Document: Room Rounds Checklist Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-73-930-B
Description:	Based on observations and staff interview, the facility failed to ensure there shall be a signaling device that terminates at a central location that is continuously staffed and permits staff to determine the origin of the signal or is audible and visible in a manner that permits staff to determine the origin of the signal. EVIDENCE: During a tour of the facility, the licensing inspector (LI) noted the signaling device system continuously beeping and noted that the beeping was on a low volume. Interview with staff revealed that this has been an issue for around 2 months and confirmed that there is a continuous beeping at the monitoring system due to a malfunction of the call light device in room 308 and that staff are able to turn the volume of the sound up and down. During on-site inspection, the LI noted that the sound of the beeping had been increased than the volume of the beeping at the beginning of the inspection.
Plan of Correction:	22VAC40-73-930-B Facility will ensure adequate audible and visible signal is properly functioning. Initiated Date: 5/29/2024 Completion Date: 6/21/2024; ongoing The Maintenance Tech and Divisional Maintenance Director has investigated root cause of facility?s call-bell system malfunctioning. Divisional Maintenance Director has order replacement call-bell cord. Once replacement is received, The Maintenance Tech will conduct a call-bell system audit weekly continuously with no end date. Audit Document: Weekly Call-bell Audit Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that criminal history record reports were obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The criminal history record report for staff person 3, date of hire 04/03/2024, was not obtained until 05/08/2024. 2. The criminal history record report for staff person 4, date of hire 03/07/2024, was not obtained until 04/15/2024. 3. The criminal history record report for staff person 5, date of hire 02/26/2024, was not obtained until 04/15/2024. 4. The criminal history record report for staff person 6, date of hire 01/10/2024, was not obtained until 03/12/2024. 5. The criminal history record report for staff person 7, date of hire 02/05/2024, was not obtained until 03/21/2024. 6. The criminal history record reports for staff person 10, date of hire 07/10/2023, and staff person 11, date of hire 07/20/2023, were not obtained until 02/01/2024. 7. As of on-site inspection, the criminal history record reports for staff persons 8, date of hire 04/10/2024, and 9, date of hire 04/01/2024, had not been obtained by the facility.
Plan of Correction:	22VAC40-90-40-B Facility will ensure that Virginia State Criminal Background Checks are received within 30 days of hire date and meet the Virginia DSS Standards of barrier crimes. Initiated Date: 6/3/2024 Completion Date: 6/10/2024; ongoing Business Office Manager will conduct audit of all current employee files to ensure that Virginia Criminal Background has been received in a timely manner. Business Office Manager will send off notarized Criminal Background Checks to Virginia State Police within 24 hours of offering employment. Upon return Executive will audit each new hire background check to ensure compliance. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee
Standard #:	22VAC40-90-40-D
Description:	Based on staff record review and document review, the facility failed to ensure that an employee has not been convicted of any of the barrier crimes when a criminal history record was requested. EVIDENCE: 1. The document ?Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs?, dated October 2023, states that a licensed assisted living facility may hire an applicant convicted of one misdemeanor barrier crime not involving abuse or neglect, or any substantially similar offense under the laws of another jurisdiction, if five years have elapsed following the conviction. 2. The record for staff person 4, date of hire 03/07/2024, contained a Virginia criminal record, dated 04/15/2024, that staff person 4 has been found guilty of 3 misdemeanor barrier crimes that are listed on the document ?Barrier Crimes for Licensed Assisted Living Facilities and Adult Day Care Programs?.
Plan of Correction:	22VAC40-90-40-D Facility will ensure that Virginia State Criminal Background Checks are received within 30 days of hire date and meet the Virginia DSS Standards of barrier crimes. Initiated Date: 6/3/2024 Completion Date: 6/10/2024; ongoing Business Office Manager will conduct audit of all current employee files to ensure that Virginia Criminal Background has been received in a timely manner. Business Office Manager will send off notarized Criminal Background Checks to Virginia State Police within 24 hours of offering employment. Upon return Executive will audit each new hire background check to ensure compliance. Person(s) responsible for implementing and monitoring each step of the corrective measures and/or preventative measures: Executive Director and/or Designee