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: Jan. 24, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-151 INTRODUCTION 22VAC40-151 ADMINISTRATION 22VAC40-151 RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCY PLANNING 22VAC40-80 THE LICENSING PROCESS .

Technical Assistance:

22VAC40-151-640 Application for Admission- protection needs

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: 1/24/2023 11:00 a.m. to 4:30 p.m This inspection was conducted by two Licensing Specialists. Number of residents in care at the beginning of the inspection: 7 A licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident?s records reviewed: 2 Number of staff records reviewed: 4 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 2 Additional Comments/Discussion: An entrance conference was conducted with the Executive Director and Program Director. Additional documentation inspected included IVE Matrix, menus, evacuation drills, and staff schedule A preliminary findings review was completed on 1/24/2023. The Acknowledgement of Inspection form was signed and left at the facility. And exit interview was conducted on 2/1/2022 by Teams Meeting. 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 #:	22VAC40-151-860-D
Description:	Violation: Based on record reviews, the facility failed to contact the division superintendent of the resident?s home locality, for Child 2 (C2), a resident with a disability. Findings: 1. The record for C2 the child?s Individualized Educational Plan (IEP) documenting the child?s disability. 2. The record for C2 did not contain documentation of the facility?s contact with the division superintendent of the resident?s home locality. 3. The findings were discussed during the preliminary findings review. 4. Staff 5 (S5) acknowledged the findings. 5. The findings were reviewed during the exit interview and staff acknowledged the findings.
Plan of Correction:	Program Director will work with the Case Manager to ensure that the required calls to division superintendents will be made during the established time period.
Standard #:	22VAC40-151-990-L
Description:	Violation: Based on review of documentation, the facility failed to maintain documentation, addressing required elements, for evacuations drills. Findings: 1. Documentation of the following evacuation drills did not include amount of time to evacuate the building: ? 11/13/2022 9:30 a.m.- Webb Cottage ? 10/17/2022 5:00 p.m.- Webb Cottage ? 12/29/22 6:00 p.m.- Buchannan Cottage
Plan of Correction:	Program Director will hold a fire drill training review with the direct care staff which will include the importance of filling in all required documentation. Program Director will review all fire drills for complience and is responsible for implementaion of the plan