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: July 28, 2022

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/28/2022from approximately from approximately 9:20am until 4:15pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 07/14/2022 regarding allegations in the area(s) of: personnel, resident care and staff training. Number of residents present at the facility at the beginning of the inspection: 76 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 11 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint but identified during the course of the investigation can also be found on the violation notice. 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 Rhonda Whitmer, Licensing Inspector at (540) 292-5932 or by email at rhonda.whitmer@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1030-B
Complaint related:	Yes
Description:	Based upon review of staff records, the facility failed to ensure that within four months of the starting date of employment, that direct care staff attended six hours of training in working with individuals who have a cognitive impairment. EVIDENCE: 1. The record for staff 1, hired on 02/07/2022, did not contain documentation of 6 hours of training in working with individuals who have a cognitive impairment. 2. The record for staff 2, hired on 01/12/2022 did not contain documentation of 6 hours of training in working with individuals who have a cognitive impairment. 3. The record for staff 3, hired on 06/27/2021 did not contain documentation of 6 hours of training in working with individuals who have a cognitive impairment. 4. The record for staff 4, hired on 01/24/2022 did not contain documentation of 6 hours of training in working with individuals who have a cognitive impairment. 5. The record for staff 5, hired on 05/15/2021 did not contain documentation of 6 hours of training in working with individuals who have a cognitive impairment.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-270-2
Complaint related:	Yes
Description:	Based on documentation review and an interview, the facility failed to ensure restraint training was completed and included all components as required. EVIDENCE: 1. Review of restraint training submitted to the LI for review is a sign-in sheet indicating due by 08/01/2022 ?Restraint Reduction Standing Orders? and an application instruction sheet for a Posey Soft Belt. 2. The training did not include the following information: demonstration, and experience in proper techniques for applying and monitoring restraints; skin care appropriate to prevent redness, breakdown and decubiti; active and active assisted range of motion to prevent contractures; observing and reporting signs and symptoms that may be indicative of obstruction of blood flow in extremities; turning and positioning to prevent skin breakdown and keep the lungs clear; provision of sufficient bed clothing and covering to maintain a normal body temperature; provision of additional attention to meet the physical, mental, emotional, and social needs of the restrained resident; awareness of possible risks associated with restraint use and methods of eliminating such risks. 3. The LI interviewed the Executive Director who confirmed there was no additional documentation of restraint training having been completed with staff.
Plan of Correction:	Not available online. Contact Inspector for more information.