VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Waterford at Virginia Beach
5417 Wesleyan Drive
Virginia beach, VA 23455
(757) 490-6672

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: Oct. 17, 2023 and Oct. 18, 2023

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 GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 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

Technical Assistance:

Resident rights posted to include current Licensing Administrator Personal Data-Keep Current for staff and residents

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: An unannounced renewal inspection took place on 10/17/2023 from 8:02 am-5:05 pm and on 10/18/2023 from 9:15 am-3:20pm. 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: 86 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 6 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 5 Observations by licensing inspector: Breakfast, and an activity were observed. A medication pass observation was completed for three residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire drills, healthcare oversight, fire inspection report, and a health inspection report. Additional Comments/Discussion: None 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 (Donesia Peoples) Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-120-A
Description:	Based on the record review the facility failed to ensure the orientation and training required in subsection B and C of this section shall occur within the first seven working days of employment. Evidence: 1. The record for staff #1, date of hire 05/22/23, did not contain documentation of an orientation and training completed within the first seven days of employment. 2. The record for staff #2, date of hire 09/14/23, did not contain documentation of an orientation and training completed within the first seven days of employment. 3. The record for staff #3, date of hire 07/25/23, did not contain documentation of an orientation and training completed within the first seven days of employment. 4. The record for staff #6, date of hire 02/23/23, did not contain documentation of an orientation and training completed within the first seven days of employment.
Plan of Correction:	1.Orientation and training will occur within the first 7 days of employment for all new employees. The Business Director and Wellness Director will audit all employee personnel files to ensure each has completed the required orientation. Any employee who has not received the required orientation will receive it by 11/15/23 or will be removed from the schedule. Staff #1 will be completed by 11/1/23 Staff #2 will be completed by 11/1/23 Staff #3 will be completed by 11/1/23 Staff #6 will be completed by 11/1/23 2.The Business Director will be in-serviced by the Executive Director by 11/06/23 on ensuring all new hires have the orientation and training within the first seven days of employment. A pre-hire paperwork checklist will be used starting 11/06/23 that contains orientation complete within 7 days of hire date. The Business Director will be responsible to check off completion of orientation within 7 days of hire. 3.The Executive Director, Business Director, or designee will ensure compliance by auditing all new employee personnel files to ensure each has completed the required orientation. Said audits will be done monthly for three months.
Standard #:	22VAC40-73-210-B
Description:	Based on the staff record review the facility failed to ensure in a facility licensed for both residential and assisted living care, direct care staff who are certified nurse aides shall attend at least 12 hours of annual training. Evidence: 1. The record for staff #4, hired 04/08/09 did not include documentation of 12 hours of annual training. The record contained documentation of 4.75 hours of training during the annual timeframe of 04/08/22-04/09/23.
Plan of Correction:	1.The Wellness Director or designee will ensure that direct care staff who are certified nurse aides shall attend 12 hours of annual training. An audit will be completed by the Wellness Director of the personnel files of all certified nurse aides to ensure each has completed 12 hours of training within the prior 12 months. Certified nurse aides that do not have the 12 hours of training within the prior 12 months, including Staff #4, will be required to complete missing hours by 11/15/23 or will be removed from the schedule. 2.The Wellness Director and designee will be in-serviced by the Executive Director on 11/06/23 on ensuring that certified nurse aides have 12 hours of training completed each year. The Wellness Director or designee shall be responsible for reviewing certified nurse aide personnel files quarterly to ensure required training is completed. 3.The Executive Director or designee will ensure compliance by auditing all certified nurse aide personnel files for annual training requirements. Said audits will be done monthly for three months.
Standard #:	22VAC40-73-210-D
Description:	Based on the staff record review the facility failed to ensure training for medication aides include continuing education required by the Virginia Board of Nursing, Evidence: 1. The Regulations Governing the Registration of Medication Aides by Virginia Board of Nursing, section 18VAC90-60-100-B, state that a medication aide shall have four hours each year of population-specific training in medication administration in the assisted living facility in which the aide is employed; or a refresher course in medication administration offered by an approved program 2. The record for staff #4, date of hire 04/08/09, a licensed medication aide (license effective date 10/17/11), did not contain documentation of completion of the continuing education required by the Virginia Board of Nursing. 3. The record for staff #5, date of hire 04/18/19, a licensed medication aide (license effective date 07/17/18), did not contain documentation of completion of the continuing education required by the Virginia Board of Nursing.
Plan of Correction:	1.The Wellness Director or designee will ensure that medication aides will complete annually either a 4 hours of population specific training in medication administration or an approved medication refresher class. An audit will be completed by the Wellness Director, or Designee of each medication aide?s files to ensure each has completed the required annual medication training. Any medication aides who have not completed the required 4 hours of annual training or approved medication refresher course will complete the required training by 11/15/23 or they will be removed from the schedule. Staff #4 will complete the required medication training by 11/22/23. Staff #5 will complete the required medication training by 11/22/23. 2.The Wellness Director and designee will be in-serviced by the Executive Director by 11/06/23 on ensuring that medication aides have required annual medication training. The Wellness Director or designee shall be responsible for reviewing medication aide personnel files quarterly to ensure required medication training is completed. 3.The Executive Director or designee will ensure compliance by auditing all medication aide personnel files for annual training requirements. Said audits will be done monthly for three months.
Standard #:	22VAC40-73-260-A
Description:	Based on the staff record review the facility failed to ensure each staff member shall maintain current certification in first aid. Evidence: 1. The record for staff #3, date of hire 07/25/23, did not contain documentation of a current certification in first aid. 2.The record for staff #5, date of hire 04/18/19, did not contain documentation of a current certification in first aid. The record contains a certification in first aid that includes an expiration date of 05/03/21.
Plan of Correction:	1.The facility will ensure that each direct care staff member maintains their current certification in first aid. An audit will be completed on all direct care staff to ensure each has a current first aid certification. Any direct care staff that do not have a current first aide certification will obtain one by 11/15/23 or they will be removed from the schedule. Staff #3 will complete his/her certification in first aid by 11/15/23 Staff #5 will complete his/her certification in first aid by 11/15/23 2.Wellness Director and/or the Assistant Wellness Director will be in-serviced by the Executive Director 11/6/23 on ensuring that each direct care staff member maintains their required first aid certification. 3.The Executive Director or designee will audit direct care staff personnel files to ensure that they have first required aid certification. Said audit will occur monthly for three months.
Standard #:	22VAC40-73-320-A
Description:	Based on the record review within 30 days preceding admission, a person shall have a physical examination completed by an independent physician. Evidence: 1. The record for resident #4, admission date 06/15/23, contains a physical examination that documents the date of the physical exam as 03/17/23. 2. The record for resident #5, admission date 01/12/23, contains a physical examination that documents the date of the physical exam as 12/05/22.
Plan of Correction:	1.The Wellness Director or designee checked each resident file to ensure each had a physical examination on file. 2.The new admissions checklist has been updated to include the requirement to check that the new resident?s most recent physical examination is dated no earlier than 30 days prior to the resident?s move-in date. The Wellness Director will be responsible to check off completion of the new admission checklist and will require new resident with a physical dated more than 30 days before the resident?s move in date to complete a new physical examination prior to admission. 3.Executive Director or designee will audit all new admission history and physical forms prior to physical date of move in for all new admissions for three months.
Standard #:	22VAC40-73-410-A
Description:	Based on the record review the facility failed to ensure upon admission, the assisted living facility shall provide an orientation for new residents and their legal guardian including emergency response procedures, mealtimes, and use of the call system. Acknowledgement of receiving the orientation shall be signed and dated by the resident and, as appropriate his legal guardian, and such documentation shall be kept in the resident?s record. Evidence: 1. The record for resident #3, admission date 06/30/23, does not contain documentation of an orientation. 2. The record for resident # 4, admission date 06/15/23, does not contain documentation of an orientation. 3. The record for resident #5, admission date 01/12/23, does not contain documentation of an orientation. 3. The record for resident #6, admission date 08/24/23, does not contain documentation of an orientation. 4. The record for resident #7, admission date 09/21/23, does not contain documentation of an orientation.
Plan of Correction:	1.The Executive Director, Business Director, or designee will audit each resident?s record to ensure that every resident (or their legal guardian if applicable) has received an orientation emergency response procedures, mealtimes, and use of the call system. The Executive Director has confirmed that Residents #3, #4, #5, #6, #7 have received an orientation. 2.The New Resident Orientation Checklist will be revised to include an acknowledgement that the resident (or legal guardian if applicable) has received an orientation to the Community include regarding emergency response procedures, mealtimes, and use of the call system. The Executive Director or designee will be responsible for ensuring this New Resident Orientation Checklist is completed for each new resident upon admission. 3.Executive Director or designee will audit all new this New Resident Orientation Checklists prior to the Resident?s admission for all new residents for three months.
Standard #:	22VAC40-73-440-A
Description:	Based on the record review the facility failed to ensure the Uniform Assessment Instrument (UAI) shall be completed prior to admission. Evidence: 1. The record for resident #5, admission date 1/12/23, contains a UAI dated 01/23/23.
Plan of Correction:	1.The Wellness Director or designee check will each resident file to ensure each had a completed Uniform Assessment Instrument (?UAI?). 2.The new admissions checklist has been updated to include the requirement to complete a UAI on or prior to admission. The Wellness Director will be responsible to check off completion of the new admission checklist and will ensure a UAI is completed for each new Resident prior to admission. 3.The Executive Director or Designee will audit all new admission checklists to ensure the UAI has been completed prior to admission for each new resident. Said audit will continue for three months.
Standard #:	22VAC40-73-450-A
Description:	Based on the record review the facility failed to ensure on or within 7 days prior to the day of admission, a preliminary plan of care shall be developed for the resident. The preliminary plan of care shall be signed and dated by the licensee, administrator, or his designee, and by the resident or his legal guardian. Evidence: 1. The record for resident #3, admission date 06/30/23, does not contain a Preliminary Plan of Care completed on or within 7 days of admission or an Individualized Service Plan (ISP) completed on the day of admission. The resident?s ISP has an effective date of 07/03/23 and is signed and dated by the facility on 08/03/23. 2. The record for resident #5, admission date 01/12/23, does not contain a Preliminary Plan of Care completed on or within 7 days of admission or an ISP completed on the day of admission. Resident?s #5 ISP has an effective date of 01/23/23 and is signed and dated by the facility on 01/23/23. Resident?s #5 progress note dated 01/12/23 document?s the resident?s move in date to the facility on 01/12/23.
Plan of Correction:	1.The Wellness Director or designee will check each resident file to ensure each has a current Individualized Service Plan (?ISP?) on file. 2.The new admissions checklist has been updated to include the requirement to complete an ISP on or prior to admission. The Wellness Director will be responsible to check off completion of the new admission checklist and ensure an ISP is completed for each new Resident prior to admission. 3.The Executive Director or Designee will audit all new admission checklists to ensure an ISP has been completed prior to admission for each new resident. Said audit will continue for three months.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the comprehensive individualized service plan shall be completed within 30 days after admission and shall include the following: a description of identified needs based upon the UAI, physical examination, and other sources; when and where the services will be provided; the expected outcome and time frame for expected outcome. Evidence: 1. Resident?s #1 ISP dated 03/03/23, did not include documentation of the following: when and where the services will be provided; the expected outcome and time frame for expected outcome; The resident?s allergy to Hyponatremia as documented on the physical examination dated 12/06/20. The resident?s code status as Do Not Rescitate (DNR) as documented on the resident?s DNR dated 12/15/20. 2. Resident?s #2 ISP dated 09/21/23, did not include documentation of the following: The resident?s allergy to penicillin, Valtrex, and oxycodone as documented on the physical examination dated 08/26/21; The resident?s mechanical needs for dressing, walking, wheeling, and the resident?s human help needs for walking as documented on the resident?s UAI dated 02/07/23. 3. Resident?s # 3 ISP dated 08/03/23 does not include documentation of the following: when and where services will be provided, and expected outcome and timeframe for expected outcome; human help needs for bathing as documented on the resident?s UAI dated 06/22/23. 4. Resident?s #6 UAI dated 08/24/23 documents a mechanical help need for toileting. The resident?s ISP dated 08/24/23 does not include the mechanical help support needed for toileting. 5. Resident?s #7 ISP dated 09/22/23 does not include documentation of the following: The resident?s mechanical needs for bathing, and needs for meal preparation, money management, and housekeeping as documented on the UAI dated 09/09/23; The resident?s allergy to gabapentin, pregabalin, aggrenex, ace inhibitors, and pork as documented on the physical examination dated 09/19/23; The resident?s code status as DNR as documented on the resident?s DNR order dated 08/10/17.
Plan of Correction:	1.The Wellness Director, Assistant Wellness Director or Designee will update each resident?s Individualized Service Plan (?ISP?) to ensure each has a description of identified needs based upon the Uniform Assessment Instrument (?UAI?); physical examination, and other sources; when and where the services will be provided; and he expected outcome and time frame for expected outcome. 2.The facility?s form ISPs will be updated to include when and where the services will be provided; and the expected outcome and time frame for expected outcome. The Executive Director will the in-service the Wellness Director and Assistant Wellness Director on 11/06/23 regarding the requirement to ensure each ISP has a description of identified needs based upon the resident?s UAI; physical examination, and other sources; when and where the services will be provided; and he expected outcome and time frame for expected outcome. 3.The Executive Director or designee will audit 10 resident ISPs per month for three months to ensure each ISP has a description of identified needs based upon the resident?s UAI; physica lexamination, and other sources; when and where the services will be provided; and he expected outcome and time frame for expected outcome.
Standard #:	22VAC40-73-450-D
Description:	Based on the record review the facility failed to ensure when hospice care is provided to a resident the assisted living facility and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the ISP. Evidence: 1. The record for resident #5 contains a hospice treatment physician order dated 09/07/23. The resident?s ISP dated 09/21/23 does not include the services provided by the hospice care organization.
Plan of Correction:	1.For all residents receiving hospice care, the Wellness Director or designee has audited each record to ensure each has a coordinated plan of care between the hospice provider and the facility. Resident #5?s record has been updated to include a coordinated plan of care between the hospice provider and the facility. 2.The Executive Director will the in-service the Wellness Director and Assistant Wellness Director on 11/06/23 regarding the requirement to document a coordinated plan of care between the hospice provider and the facility for all residents receiving hospice care. 3.The Executive Director or designee will ensure compliance by auditing the records of all residents receiving hospice care to ensure each has a coordinated plan of care between the hospice provider and the facility. Said audits will be done monthly for three months.
Standard #:	22VAC40-73-650-E
Description:	Based on the record review the facility failed to ensure the resident?s record shall contain the physician?s or other prescriber?s signed written order or a dated notation of the physician?s or other prescriber?s oral order. Evidence: 1. Resident?s #1 Medication Administration Record (MAR) dated 10/2023 documents the resident is prescribed Certavite TAB Senior, Citalopram, and Docusate Sodium. During the medication pass observation for resident #1, staff #2 administered Certavite TAB Senior, Citalopram, and Docusate Sodium to the resident. The resident?s record does not contain a physician order signed by the physician or other prescriber or a dated notation of the physician or other prescribers oral order for Certavite TAB Senior, Citalopram, and Docusate Sodium.
Plan of Correction:	1.The Wellness Director, Assistant Wellness Director or Designee will review and audit all residents? charts to ensure all orders are placed in the chart correctly and inserted under the correct tab. A current medication order was obtained for Resident #1 which confirms Resident #1 was receiving the correct medication. 2.Wellness Director or designee will in-service all Registered Medication Aides by 11/15/23 related to filing of physician orders in resident medical records. The Wellness Director or Designee will verify all orders are correct and signed the resident?s physician prior to its placement in the Medication Administration Record (?MAR?). A checklist form will be implemented for the Wellness Director or designee to sign off that this process has been completed for all orders placed in a resident?s MAR. 3.Wellness Director or designee will audit 10 resident records a month for three months to ensure each has a current physician-signed medication order that matches the resident?s MAR.
Standard #:	22VAC40-73-680-H
Description:	Based on the record review the facility failed to ensure the MAR shall include date and time given and initials of direct care staff administering the medications; any medication errors or omissions. Evidence: 1. Resident?s #2 MAR dated 10/2023 does not include documentation of an omission or administration of the following medications on 10/16/23 at night at bedtime: Carbamazepine 200mg; Gabapentin 300mg; Mag Oxide 400mg; Olanzapine 7.5mg; Melatonin 3mg.
Plan of Correction:	1.The Wellness Director reviewed Resident?s #2 MAR Dated 10/16/2023. The electronic MAR system showed that all Resident #2 medications were signed as administer on 10/16/23. 2.All Medication Aides will receive training education quarterly regarding correct procedures of Medication Administration, including the documentation of an omission or administration. 3.The Wellness Director or designee will audit the medication exception report weekly for three months.
Standard #:	22VAC40-73-950-F
Description:	Based on review the facility failed to ensure the facility shall review the emergency preparedness plan annually. Evidence: 1. The facility did not provide documentation of an annual review of the facility?s emergency preparedness plan.
Plan of Correction:	1.The Executive Director and will review the Emergency Preparedness Binder and update the Emergency Preparedness Binder by 11/22/23. 2.The Regional Operations Director will in-service the Executive Director regarding the maintaining and reviewing the Emergency Preparedness Binder on or before 11/15/23. 3.The Executive Director will be responsible for reviewing and updating the Emergency Preparedness Binder quarterly and documenting this review.
Standard #:	22VAC40-73-990-C
Description:	Based on review the facility failed to ensure at least every six months, all staff currently on duty on each shift shall participate in an exercise in which the procedures for resident emergencies are practiced. Documentation of each exercise shall be maintained in the facility for at least two years. Evidence: 1. The facility did not provide documentation of staff participation in an exercise in which the procedures for resident emergencies were practiced every 6 months.
Plan of Correction:	1.The Maintenance Director/designee will perform all exercises on each shift by 15th of each month for 3 months and monthly ongoing there after. 2.The Maintenance Director has calendared emergency exercises for the next 12 months. The Executive Director will in-service the Maintenance Director of how to perform and document the emergency exercise on or before 11/06/23. 3.The Executive Director or designee will be responsible for to ensure an emergency exercise is conducted monthly on each shift monthly for three months.
Standard #:	22VAC40-90-30-B
Description:	Based on the staff record review, the facility failed to ensure the sworn statement or affirmation shall be complete for all applicants for employment. Evidence: 1. The record for staff #1, date of hire 05/22/23, does not contain a sworn statement or affirmation. 2. The record for staff #6, date of hire 02/23/23, does not contain a sworn statement or affirmation. 3. The record for staff # 7, date of hire 06/26/23, does not contain a sworn statement or affirmation.
Plan of Correction:	This plan of correction is submitted as required under State and Federal law. The submission of this Plan of Correction does not constitute an admission on the part of The Waterford at Virginia Beach as to the accuracy of the surveyors? findings or the conclusions drawn there from. Submission of this Plan of Correction also does not constitute an admission that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Community?s policies and procedures should be considered subsequent remedial measures as that concept is employed in Rule 407 of the Federal Rules of Evidence and any corresponding state rules of civil procedure and should be inadmissible in any proceeding on that basis. The Community submits this plan of correction with the intention that it be inadmissible by any third party in any civil or criminal action against the Community or any employee, agent, officer, director, attorney, or shareholder of the Community or affiliated companies. 1.Sworn statements were completed for staff #1, #6 and #7. 2.An audit of all personnel files will be completed by 11/22/23 to ensure all current staff have a sworn statement or affirmation signed. The Business Director will be in-serviced by the Executive Director 11/6/23 on ensuring each applicant for employment has completed a a sworn statement or affirmation. A pre-hire paperwork checklist will be used starting 11/06/23 that contains the sworn statement requirement. The Business Director will be responsible to check off completion of required items including the sworn statement. The Executive Director will be required to sign the checklist to ensure all required items are complete on the new hire. 3.The Executive Director, Business Director, or designee will ensure compliance by auditing all new employee personnel files for a signed sworn statement or affirmation. Said audit will be conducted monthly for 3 months.
Standard #:	22VAC40-90-40-B
Description:	Based on the staff record review, the facility failed to ensure the criminal history record report was obtained on or prior to the 30th day of employment for each staff person. Evidence: 1. The record for staff # 1, date of hire 5/22/23, does not contain a criminal history report. 2. The record for staff # 10, date of hire 5/22/23, contains a criminal history record report dated 08/02/23. 4. The record for staff #11, date of hire 5/11/23, contains a criminal history record report dated 01/19/23. Staff #8 confirmed staff #11 was not a re-hired staff. 5. The record for staff # 12, date of hire 5/11/23, contains a criminal history record report dated 08/02/23. 6. The record for staff # 13, date of hire 5/04/23, does not contain a criminal history report. 7. The record for staff # 14, date of hire 10/24/22, contains a criminal history record report dated 01/18/23. 8. The record for staff # 15, date of hire 10/25/22, contains a criminal history record report dated 01/19/23. 9.The record for staff # 16, date of hire 06/06/23/23, contains a criminal history record report dated 08/02/23. 10. The record for staff # 17, date of hire 11/10/22, contains a criminal history record report dated 01/18/23. 11. The record for staff # 18, date of hire, 11/28/22, contains a criminal history record report dated 01/18/23.
Plan of Correction:	1.The Community completed an audit and has obtained a criminal history record report for all staff members, including the following individuals identified in the survey: Staff #1's criminal history record report was obtained on 8/2/23. Staff #6?s criminal history record report was obtained on 2/13/23. Staff #10's criminal history record report was obtained on 8/2/23. Staff #11's criminal history record report was obtained on 1/19/23. Staff #12's criminal history record report was obtained on 8/2/23. Staff #13 is not employed by the Community. Staff #14's criminal history record report was obtained on 1/18/23 Staff #15's criminal history record report was obtained on 1/19/23 Staff #16's criminal history record report was obtained on 8/2/23 Staff #17's criminal history record report was obtained on 1/18/23 Staff #18's criminal history record report was obtained on 1/18/23 2.The Business Director will be in-serviced by the Executive Director on 11/06/23 on obtaining a criminal history record report on or prior to the 30th day of employment for each staff member. A pre-hire paperwork checklist will be used starting 11/06/23 that contains the VA state crime check. The Business Director will be responsible to check off completion of required items including the VA state crime check. The Executive Director will be required to sign the checklist to ensure all required items are complete on the new hire. 3.The Executive Director, Business Director, or designee will ensure compliance by auditing all new employee personnel files to ensure each has a criminal history record report within 30 days of hire. Said audits will be done once a month for three months to ensure compliance.
Standard #:	22VAC40-90-40-C
Description:	Based on the onsite record review the facility failed to ensure any person required to obtain a criminal history report shall be ineligible for employment if the report contains convictions of barrier crimes. Evidence: 1. Staff #8, date of hire 09/21/23, criminal record report contains two convictions for barrier crimes (18.2-57). 2. Staff #9, date of hire 07/06/23, criminal record report contains two convictions for barrier crimes (18.2-57 and 18.2-51).
Plan of Correction:	1.The community will not employ any person deemed ineligible for employment if the report contains convictions of barrier crimes per the regulation. An audit was completed to ensure all current staff have a criminal history record report in their personnel file that does not contain a barrier crime. The following individuals identified in the survey as having barrier crimes are no longer employed by the Community: Staff #8 and Staff #9. 2.The Business Director will be in-serviced by the Executive Director on 11/06/23 to ensure all staff have a criminal history record report that does not contain a barrier crime and on procedures for terminating the employment of any staff who do have a barrier crime on their criminal history record report. A pre-hire paperwork checklist will be used starting 11/06/23 that contains the VA state crime check. The Business Director will be responsible to check off completion of required items including that the VA state crime check does not have barrier crimes within 5 years. If a barrier crime is on the VA state crime check then it will be reviewed with Human Resources to ensure the employee meets criteria for employment and that only one barrier crime is on the VA state crime check. The Executive Director will be required to sign the checklist to ensure all required items are in compliance on the new hire. 3.The Executive Director, Business Director, or designee will ensure compliance by auditing all new employee personnel files to ensure each has a criminal history record report does not contain a barrier crime. Said audits will be done once a month for three months to ensure compliance.