VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living Communities
201 & 202 Lillian Lane
Lynchburg, VA 24502
(434) 385-5102

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: March 23, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 22VAC40-80 COMPLAINT INVESTIGATION.

Comments:

The licensing inspector for Heritage Green Assisted Living conducted an unannounced complaint inspection via phone in response to a complaint that was received by the licensing office on 03/13/2020. The LI reviewed documentation for one resident and conducted phone interviews with two staff relating to allegations that a resident was involved in an altercation with another resident, sustained an injury; unknown if resident received medical care, and staff member was informed not to document the incident or contact the resident?s family. Also, the complaint included an allegation that there is a shortage of staff at the facility. The information gathered during the investigation does not support the allegation of the resident not receiving medical care or the resident?s family not being contacted; however, the information gathered during the investigation supports the staff shortage allegation. Based on the preponderance of evidence the complaint is determined to be valid. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it to your licensing inspector within 10 calendar days from today. You will need to specify how the deficient practice will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). If you have any questions, contact your licensing inspector at (540) 589-5216.

Violations:

Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on document review and staff interview, the facility failed to ensure that for every additional 10 residents there was at least one more direct care staff member awake and on duty in the unit. EVIDENCE: 1. The DAYBREAK 1ST (shift) staff schedule for the facility?s first shift showed that on 02/16/2020, 02/29/2020, 03/01/2020 and 03/15/2020 there were only four direct care staff on duty. Interview with staff 1 revealed that the census for 02/16/2020 was 41 residents in care, the census for 02/29/2020 and 03/01/2020 was 42 residents in care, and the census for 03/15/2020 was 45 residents in care. 2. The DAYBREAK 2nd (shift) staff schedule for the facility?s second shift showed that on 02/15/2020, 02/16/2020, 02/28/2020, 02/29/2020, 03/14/2020 there were only four direct care staff on duty. Interview with staff 1 revealed that the census for 02/15/2020 and 02/16/2020 was 41 residents in care, the census for 02/28/2020 and 02/29/2020 was 42 residents in care and the census for 03/14/2020 was 45 residents in care. 3. The DAYBREAK 3rd (Shift) staff schedule for the facility?s third shift showed that on 02/02/2020, 02/15/2020, 02/16/2020, 02/18/2020, 02/29/2020, 03/01/2020, 03/06/2020, 03/07/2020, 03/08/2020, 03/12/2020, 03/13/2020, 03/14/2020 and 03/15/2020 there were only four direct care staff on duty. Interview with staff 1 revealed that the census for 02/02/2020, 02/15/2020, 02/16/2020 and 02/18/2020 was 41 residents in care, the census for 02/29/2020, 03/01/2020, 03/06/2020 and 03/07/2020 was 42 residents in care and the census for 03/12/2020, 03/13/2020, 03/14/2020 and 03/15/2020 was 45 residents in care.
Plan of Correction:	What: On the identified dates the Community had four awake staff for 40+ residents and did not meet the required State staffing ratio. How: The Community's Executive Director, Resident Care and Memory Care Director implemented a variety of successful recruitment measures to hire the required new staff. The community is now fully staffed and running with the appropriate staffing on all shifts. The Memory Care Director is aware that 41-50 residents require 5 staff on all shifts. The Executive Director put into place a system where all staff schedules are reviewed on a shift-by-shift basis to ensure that proper staffing is in place. When a potential staffing shortage is identified procedures, including the use of managers are activated. Schedules attached as Exhibit A. On-going. Executive Director or designee will proactively review the schedules daily and the results will be reviewed at the Quarterly Quality Assurance meeting.