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: May 20, 2020

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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.

Technical Assistance:

450 C, 325 B

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 05/19/2020 and concluded on 05/20/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 94. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 5 resident records, 5 staff records, facility health care oversight, fire drills, health department inspection, dietitian oversight, and staff schedules submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-B
Description:	Based on staff record review, the facility failed to ensure all direct care staff had attended at least 18 hours of training annually. EVIDENCE: 1. The record for staff 2 did not contain documentation that staff 2 had received 18 hours of annual training.
Plan of Correction:	What: Staff 2?s training record from July 24, 2018 ? July 25, 2019 showed 17 hours of training, short 1 hour of the 18 hours required in the anniversary year. How: Staff 2 is now in her July 24, 2019 ? July 25, 2020 anniversary year. Resident Care Director, Memory Care Director or designee will ensure Staff 2 receive 18 hours of training by July 25, 2020. RCD, MCD or designee will ensure all care staff have completed their scheduled training on a monthly basis, using the Relias completion report, Exhibit C. Business Office Director or designee will use anniversary years to audit staff?s annual training. Ongoing: Executive Director or designee will audit 15% of staff training records monthly for a bi-annual review of all staff?s training record using the staff training audit tool, Exhibit B, as part of the Quarterly Quality Assurance Meeting.
Standard #:	22VAC40-73-210-F
Description:	Based on staff record review, the facility failed to ensure all staff had at least two hours of infection control and prevention training annually. EVIDENCE: 1. The record for staff 1 contained documentation of only 1.75 hours of annual infection control and prevention training. 2. The record for staff 2 contained documentation of only 1 hour of annual infection control and prevention training.
Plan of Correction:	What: Staff 1?s training record from 4/17/2019 to 4/18/2020 contains 1.75 hours of annual infection control and prevention training, short.25 hours or 15 minutes of training. Staff 1 was assigned an additional infection control course in April 2020 through Relias and has not yet taken this course. How: Staff 1 will complete the additional infection control course in Relias by June 5, 2020. Resident Care Director, Memory Care Director or designee will ensure staff are completed their assigned Relias each month, using the Relias course completion report, Exhibit C. Ongoing: Executive Director or designee will audit 15% of staff training records monthly for a bi-annual review of all staff?s training record using the staff training audit tool, Exhibit B, as part of the Quarterly Quality Assurance Meeting.
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review, the facility failed to ensure that all direct care staff members received certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff 3, date of hire 12/05/2019, contained documentation that staff 3 did not complete first aid training until 02/25/2020.
Plan of Correction:	What: Staff 3 should have completed first aid training by 2/4/2020 and was 21 days late in completing this training. CPR and First Aid training is offered at the facility monthly and was offered December 5, 2020, January 28, 2020 and in addition the February 25, 2020 class. Staff 3 should have attended the January 28, 2020 class at the facility or taken an alternate training on her own. How: Resident Care Director, Memory Care Director or designee will ensure staff are completing their CPR / First Aid training within 60 days of employment, using the staff chart audit tool, Exhibit A. Staff will be taken off the schedule when they have not met this requirement until they complete the training. Ongoing: Executive Director or designee will audit staff training records on a quarterly basis as part of the Quarterly Quality Assurance Meeting.
Standard #:	22VAC40-90-30-B
Description:	Based on staff record review, the facility failed to ensure that a sworn statement or affirmation (SD) was completed for all applicants for employment. EVIDENCE: 1. Staff 8, date of hire 05/15/2020, completed the SD after employment on 05/18/2020. 2. Staff 9, date of hire 03/06/2020, completed the SD after employment on 03/08/2020. 3. Staff 10, date of hire 09/12/2019, completed the SD after employment on 09/16/2020. 4. Staff 11, date of hire 03/25/2020, completed the SD after employment on 03/27/2020. 5. Staff 12, date of hire 05/04/2020, completed the SD after employment on 05/07/2020. 6. Staff 13, date of hire 03/27/2020, completed the SD after employment on 03/29/2020.
Plan of Correction:	What: Staff persons 8, 9, 10, 11, 12, 13 all have a completed sworn disclosure statement dated prior to start date at facility, but not prior to hire date. How: Business Office Director will ensure all staff have completed the sworn disclosure statement prior to hire date during the time of hire. Ongoing: Executive Director or designee will audit staff charts on a quarterly basis as part of the Quarterly Quality Assurance Meeting to ensure these are done prior to hire date.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure that a criminal history record report was obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. The record for staff 4, date of hire 12/11/2019, did not contain documentation that a criminal history record report was obtained within the first 30 days of employment. 2. Discussion was held with staff 5 on day of inspection in which a criminal history record report was requested for staff 4 and one was not provided.
Plan of Correction:	What: Staff 4 was hired 12/11/2019 and a criminal background check was requested 12/11/2019 with a copy of this request provided upon inspection. The resulting criminal background check could not be located on the day of inspection for staff 4. How: Business Office Director requested another criminal background check for staff 4 on 5/21/2020. The Business Office Director will utilize the staff chart audit tool, Exhibit A, to ensure all criminal background checks are checked off as they arrive and filed in the personnel record of all staff. Ongoing: Executive Director or designee will review personnel records for criminal background checks at the Quarterly Quality Assurance Meeting.
Standard #:	22VAC40-90-40-C
Description:	Based on staff record review, the facility failed to ensure that any person required by this chapter to obtain a criminal history record report shall be ineligible for employment if the report contains convictions of the barrier crimes. Due to changes, ? 63.2-1720 of the Code added that a licensed assisted living facility may hire an applicant or continue to employ a person convicted of one misdemeanor barrier crime not involving abuse or neglect, or any substantially similar offense under the laws of another jurisdiction, if five years have elapsed following the conviction. EVIDENCE: 1. The record for staff six contained a ?Virginia Criminal Record? dated 03/24/2020 that showed staff was found guilty of the barrier crime Misdemeanor Assault 18.2-57 on 05/05/2015. This staff person would have been eligible for hire on 5/15/2020; but was hired on 03/11/2020, and five years had not elapsed since the conviction.
Plan of Correction:	What: Staff 6?s criminal record showed that staff was hired 4 years 10 months and 6 days after being found guilty, therefore short of 1 month and 24 days of being 5 years. How: Staff 6 would have been eligible for hire on 5/5/2020 and the inspection took place on 5/20/2020, so staff 6 was retained as an employee. Ongoing: Executive Director or designee, when reviewing criminal background checks, for staff who have had prior barrier crimes, will calculate the time span precisely, documenting the calculation of time and filing that with the criminal background check