VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mission House
516 W. Spotswood Trail
Elkton, VA 22827
(540) 298-8917

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: July 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 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

Technical Assistance:

Make sure shift designations are indicated for the quarterly fire drills since staffing has resulted in variable shift times since Covid. ?0?/Zero for sliding scale needs no explanation since it is an order like any other. Discuss with pharmacy all information regarding glucose monitoring and insulin administration all in one place. Review with physician the need for consistency in parameters of when to and not to administer certain medication, especially insulin and when to contact physician.

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: 7/18/23 The Acknowledgement of Inspection form was signed and left at the facility on the date of the inspection. Number of residents present at the facility at the beginning of the inspection: 15. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. The facility recently received a grant and now have central heat and air throughout the entire building. They have elected to keep the baseboard heaters in place and have been painting them. The building was clean and odor free. Number of resident records reviewed: 10 Number of staff records reviewed: 6 Number of interviews conducted with residents: 6 Number of interviews conducted with staff: 13 Observations by licensing inspector: The facility has no special diets. Postings were as required. Many of the facility activities are provided by outside individuals or groups which the residents indicated they really enjoy. Medication cart was organized, count correct and med pass met Board of Nursing guidelines. Additional Comments/Discussion: Fire ? 6/22/23 Health ? 4/20/23 An exit meeting was 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 had 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. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. Thank you to residents and staff for your cooperation during this monitoring inspection process. Should you have any questions, please contact Sharae Henderson, Licensing Administrator at (804) 726-7833 or by email at sharae.henderson@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on a review of six staff records none of the six were complete as per the standard requirements. Missing items included incomplete orientation documentation, annual TB screenings, annual resident rights, job descriptions and updated CPR/First aid documentation.
Plan of Correction:	Staff files are the responsibility of the owner who has not been in the area recently. The administrator will work with necessary providers to get what is needed to bring the staff records into compliance. Discussion will be held with the owner to determine how compliance is to be handled in the future. Correction date is for full compliance.
Standard #:	22VAC40-73-350-B
Description:	There was no documentation that sex offender status had been ascertained on residents A and B prior to their move to the facility.
Plan of Correction:	The owner has access to the registry and is the only one who can run the checks. She has been traveling and not available to the facility. A discussion will be had upon her return to allow that task to be completed by the administrator or admissions will be held until she is able to provide the information. Both individuals came from other facilities.
Standard #:	22VAC40-73-450-A
Description:	Based on a review of 10 resident records, full or partial, two residents (A and B) recently admitted did not have an initial service plan. Residents G and I had plans that expired 5/23. All the residents who did not have plans are independent in all ADLs.
Plan of Correction:	Due to a healthcare staffing shortage the administrator has also been working the floor to assist with resident care multiple days per week as care must come first. All files will be reviewed, and plans developed on made current. The administrator assumes responsibility for correction and future compliance.
Standard #:	22VAC40-90-40-B
Description:	The facility did not have documentation of four background checks being completed within thirty days of hire. There was documentation of references being checked in the files.
Plan of Correction:	The owner has access to the registry and is the only one who can run the checks. She has been traveling and is not available to the facility. Due to staffing shortages and after reviewing references the staff were hired. They always work with someone else in the building. A discussion will be had upon her return regarding the need for timely submission and return of documentation for staff to be hired and continue employment.