VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Mission House
516 W. Spotswood Trail
Elkton, VA 22827
(540) 298-8917

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: July 6, 2021

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 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Although it is expectable to have an extra emergency glucometer on hand when you have someone in the facility who requires monitoring several times daily it cannot be used to simply randomly monitor multiple individual's blood glucose levels as was proposed by the owner. As explained, all monitoring requires a physician's order and each individual must have their own equipment labeled like you have for the resident who currently requires monitoring.

Comments:

A renewal inspection was initiated on July 6, 2021 and concluded on July 14, 2021. The administrator was contacted by telephone and email to initiate the inspection. The administrator reported that the current census was 15. The inspector emailed the administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector, based on the facility census as per the hybrid protocol, reviewed two resident records, two staff records, fire inspection, health inspection, health care oversight, fire drills and emergency drills and staff schedule submitted by the facility to ensure documentation was complete. The inspector conducted the on-site portion of the inspection on July 12, 2021 and reviewed required postings related activities, emergency food supply, general building and grounds and medication cart. An exit interview was conducted with administrator and owner on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and a violation was documented on the violation notice issued to the facility. Thank you to staff and residents for your cooperation during this hybrid inspection process. Should you have additional questions or concerns please call (540) 332-2330 or email this inspector at sharon.deboever@dss.virginia.gov. The facility will be notified by mail regarding their renewal status.

Violations:

Standard #:	22VAC40-73-950-C-1
Description:	Based on an interview with the administrator (7/12/21) and follow up with facility owner(7/14/21), the facility no longer has a vendor capable of providing the facility with an emergency generator for the provision of electricity during an interruption of the normal electric power supply. They have a contract with a local church to move residents in the event of a power outage but the church does not have an emergency generator as per the owner.
Plan of Correction:	The owner has discussed this with the church and they will be purchasing emergency generators that can meet the needs of the residents in the event they have to be housed at the church building. The owner will notify licensing when this process is complete. The facility is capable of preparing food in the facility in the event of a short term loss and have emergency lighting but cannot regulate heat or air in the event of a power loss.