VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Presbyterian Children's Home of Highland
425 Grayson Road
Wytheville, VA 24382
(276) 228-2861

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: Dec. 16, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-151 22VAC40-151 III. RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCEY PLANNING 63.2 Facilities and Programs..

Comments:

An unannounced monitoring inspection was conducted by two inspectors on December 16. 2019 from 9:12 a.m. to 2:50 pm The facility reports a total of twelve (12 ) children in placement: six (6) girls and six (6) boys. During this inspection records were reviewed for two current residents, two discharge resident, and three personnel. Two new staff were hired. A sampling of staff was reviewed against the CRF Employee Matrix. Interviews were conducted with two staff and two residents. A tour of the facility?s exterior, the interior of Webb Cottage, and the interior of the Administration building were completed. Residential environment requirements were assessed. The following was reviewed for the past six months: daily communication logs, grievances, menus, staff work schedules, incident reports, emergency evacuation drill documentation, medication administration records, readily accessible medical information, and fire and sanitation inspection documentation. An exit interview was conducted at the conclusion of the inspection with the Executive Director, Program Director, Compliance Director, Case Manager, and Administrative Director to review preliminary inspection findings. An acknowledgement form was signed. There were two violations. Upon the receipt of the violation notice, the licensee should identify the necessary corrective action and develop a plan of correction for each violation. The plan of correction should include the following: The steps to correct noncompliance with the standard(s); measures to prevent re-occurrence of noncompliance; person(s) responsible for implementation and monitoring of preventative measure(s); and date by which noncompliance will be corrected. The licensee has five (5) calendar days from receipt of the inspection documentation to complete the section titled Plan of Correction, sign each page of the documentation and return it to the Licensing Office. The licensee should retain a copy to be posted at the facility. Results of the inspection documentation will be posted on the VDSS web page and available for review by the general public. Do not write any names or other confidential information into your plan of correction.

Violations:

Standard #:	22VAC40-151-620-B-4
Description:	Based on record review and interview, the facility failed to fully complete an application for admission for current resident 1 (CR1). Findings: The record for CR1 included an application for admission that did not include information regarding the child?s protection needs. The application was left blank for the response to this question. The finding was discussed with facility staff during the exit interview. Facility staff reviewed the application and acknowledged the finding.
Plan of Correction:	Compliance Director will review all applications to ensure completion of all sections of the document. Any blank sections will be completed immediately. The Compliance Director is responsible for the implementation of this action.
Standard #:	22VAC40-151-660-E-1
Description:	Based on record reviews and interview, the facility failed to conduct progress reviews within 60 days of the date of the initial service plans for current resident 1 and 2. (CR1 and CR2). Findings: The case records for CR1 and CR2 did not contain quarterly progress review reports. The finding was discussed with facility staff during the exit interview. Facility staff acknowledged the reviews were not completed or placed in the records.
Plan of Correction:	Case manager will be directed to complete and file reports within the required timeframes. The Compliance Director will review the files and ensure that all reports are completed within the proper timeframes. The Compliance Director is responsible for the implementation of this action.