VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Joy Ranch, Inc.
813 Joy Ranch Road
Woodlawn, VA 24381
(276) 236-5578

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: Dec. 6, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-151 INTRODUCTION. 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 6. 2019 from 8:47 a.m. to 2:19 p.m. The facility reports a total of eight (8) children in placement: four (4) girls and four (4) boys. During this inspection records were reviewed for one current resident, one discharged resident, and four personnel. Two new staff were hired. A sampling of staff were reviewed against the CRF Employee Matrix. Interviews were conducted with four staff. A resident interview did not occur during this inspection due to there being no residents on campus. A tour of the facility?s exterior, the interior of Leebrick 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, Community Manager, Program Assistant, Administrative and Human Resources Director, Community Services Director, and Residential Care Director to review preliminary inspection findings. An acknowledgement form was signed. There were four 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 #:	22VAC40-151-240-B-1
Description:	Violation: Based on a review of the personnel records for personnel 1, 2, and 3 (P1, P2, and P3), the agency failed to include all required documentation in the personnel records. Evidence: The Applications for Employment for P1, P2, and P3 did not contain a social security number or other unique identifier.
Plan of Correction:	Social Security numbers are included in the employee files, just not on the Employment Application. After an offer of employment is rendered by Joy Ranch, the Human Resource Director will now manually write the individual's SS# on their Employment Application form.
Standard #:	22VAC40-151-360-C
Description:	Violation: Based on a review of facility records and interview with personnel, P7, an annual inspection of the buildings and equipment in accordance with the Virginia Statewide Fire Prevention Code did not occur. Evidence: The last fire inspection for the facility was over thirteen months ago. P7 verified that a subsequent inspection has been requested from local authorities but not yet scheduled.
Plan of Correction:	To be determined by the Carrol County Fire Marshall. As identified at the time of the Unannounced Monitoring inspection, Joy Ranch has made multiple phone contacts with the Fire Marshall explaining the mandated need for a Fire Inspection. Their office has stated it will be December 2019 or January 2020 at the earliest before they can complete this inspection due to an excessive workload.
Standard #:	22VAC40-151-720-C
Description:	Violation: Based on a review of serious incident reports for a resident, CR2, review of daily communication logs, and interview with S1, the daily communication log did not document significant happenings or problems experienced by CR2 . Evidence: 1. Serious incident reports for CR2 documented significant happenings and problems. The significant happenings and problems were not documented in the daily communication log. 2. S1 did not have additional evidence to provide to demonstrate compliance.
Plan of Correction:	(1) Joy Ranch is changing to the Extended Reach software program effective January 1, 2020. to provide proper documentation in all areas of compliance. We will no longer use our Daily Narratives to document significant happenings. This new system will require all documentation to be done on the Communication Log. (2) With the new system, all staff will have immediate access to specific details within every resident's file.
Standard #:	22VAC40-151-840-I-7
Description:	Violation: Based on a review of the record for a resident, CR2, and interview with staff, S6, documentation of an application of physical restraint did not record a required component. Evidence: The report documenting an application of physical restraint used with CR2 did not include a description of method or methods of physical restraint techniques used as required by 22VAC40-151-I.7. S6 acknowledged that the report did not contain the missing element.
Plan of Correction:	The new Serious Incident Report on the Extended Reach system will include a place to document specific information on physical restraints including technique of restraint and duration.