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: June 13, 2022 and June 14, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-151 ADMINISTRATION 22VAC40-151 RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES

Technical Assistance:

Additional discussion occurred regarding the following standards: 22VAC40-151-700 Case Management documentation 22VAC40-151-750 Medication errors policies and procedures 22VAC40-151-250 Staff Development required training

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 6/13/2022 10:35 a.m. to 3:30 p.m. This inspection was conducted by two Licensing Specialists Number of residents in care at the beginning of the inspection: 9 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident?s records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: Number of interviews conducted with staff: 2 Additional Comments/Discussion: .An entrance conference was conducted with the Executive Director and Program Director. A Additional documentation inspected included IVE Matrix, menus, health and fire inspections, pool inspection, and one vehicle used to transport residents. A preliminary findings review was completed on the date of inspection. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Inspection documentation was provided to the Program Director and Executive Director prior to the exit interview. The exit interview was conducted on 6/14/2022 with the Executive Director by phone. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Dawn Caldwell, Licensing Inspector at 804-385-6864 or by email at dawn.caldwell@dss.virginia.gov

Violations:

Standard #:	22VAC40-151-250-B-1
Description:	Violation: Based on record review and interviews, the facility failed to ensure all employees completed an annual refresher emergency preparedness and response training. Findings: 1. The record for S1 did not contain documentation of annual refresher emergency preparedness and response training. 2. Staff 5 and 7 (S5 and S7) were interviewed. 3. S5 indicated the training did not occur and acknowledged the findings.
Plan of Correction:	Facility will provide a refresher course in emergency preparedness training as soon as possible and will schedule trainings on an annual basis going forward