VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Inspirit Hilltop Operator LLC
111 Denny Lane
Winchester, VA 22603
(540) 667-5323

Current Inspector: Jill James (540) 418-2631

Inspection Date: Oct. 5, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

A non-mandated self-report inspection was initiated on 10/05/2021 and concluded on 10/07/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the self-report of non-compliance with standards or law, and a violation was issued. Any violations not related to the self-report, but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-450-E
Description:	Based on review of resident's record, the facility failed to ensure the Individualized Service Plan (ISP) is signed and dated by the person who has developed the plan and by the resident or legal representative. EVIDENCE: The ISP for resident 1 dated 09/24/2021 is not signed by the person who developed the plan and does not contain a signature or date of the resident's legal representative.
Plan of Correction:	RWD along with the RCD will ensure that all ISPs are reviewed and signed with family to ensure that needs are being met. ED will also review and follow-up with RDW and RCD for completion.
Standard #:	22VAC40-73-460-D
Description:	Based on documentation review and an interview the facility failed to provide supervision to prevent resident wandering from the premises. EVIDENCE: 1. The "State Incident Report" submitted on 09/26/2021 indicates resident 1 (admitted 09/23/2021) "exited the wander-guard neighborhood unsupervised with no audible alarm heard by team members and managed to exit the building on 09/25/2021 at 11:30am. "Care staff identified the resident was missing, upon discovering he was not in the wander-guard neighborhood, care staff conducted a community search for the resident. 2.The "State Incident Report" submitted on 09/26/2021 indicates staff 1 reported not knowing the individual resided in the community and allowed the resident to exit the doors. 3. The "State incident Report" submitted on 09/26//2021 indicates a resident in the lobby stated they observed the resident enter a car in the parking lot and leave the community grounds. 4. The State Incident Report" submitted on 09/26/2021 indicates a search of the grounds was conducted and 911 was called. 5. Communication received via email from the facility on 10/05/2021 indicates resident 1 found the keys that staff 2 had left in her vehicle and drove the car from the facility. 6. Communication received via email from the facility on 10/05/2021 indicates resident 1 was gone from the facility for approximately 3 hours and was located by the sheriff's office and returned to the facility unharmed. 7. The LI interviewed the administrator on 10/05/2021 who confirmed staff 1 failed to recognize resident 1 was from the wander-guard neighborhood ,resident exited the building and took vehicle owned by staff 2 and left facility grounds. 8. The LI interviewed the administrator on 10/06/2021 who confirmed resident was away from the facility for approximately 3 hours and was returned by the sheriff's office unharmed. 9. The Uniform Assessment Instrument (UAI) for resident 1, dated 09/24/2021 indicates resident has a behavior pattern of wandering and is disoriented to time, place and situation. The Individualized Service Plan dated 09/24/2021 indicates resident is an elopement risk and that resident will remain safe and will be monitored very hour. 10. The September Medication Administration Record (MAR) indicates "check on resident every hour for monitoring". There is no documentation indicating resident is being monitored every hour until 09/29/2021 at 2:00am.
Plan of Correction:	1. Wander Guard neighborhood door was equipped with an audible alarm each time the door open to alert staff of entrance and exits of that area. Maintenance will ensure that the batteries are in working order and the ED will follow-up. 2. There was a chart started at the front desk with full body pictures of each resident in the Wander Guard Neighborhood along with a demographic sheet. This chart will be updated with each move in to this neighborhood by the Laurel neighborhood lead staff and followed up on by the RWD and RCD. 3. UAIs will be reviewed and updated to reflect medication administration by lay person by RWD and RCD. ED will review to ensure completion. 4. Documentation will be added on the MAR to reflect each shift is rounding and checking resident hourly. RWD and RCD will monitor to ensure resident safety. 5. Every visitor that comes to the community must sign in and wear a visitor badge. Team members instructed to ensure that guests are wearing a visitor badge when allowing them to exit the door. BOM along with ED will make sure that the visitor badges and sign-in and sign out sheets are at the front desk at all times.