VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hope Haven
24532 Prince Edward Highway
Rice, VA 23966
(434) 392-9276

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 30, 2019

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS.

Comments:

The LI for Hope Haven conducted an unannounced renewal study at the facility on 5/30/19 from 9am until 1pm and noted 6 residents to be in care. Resident and staff records as well as other forms of facility documentation were reviewed. Interviews were conducted with staff. A tour of the facility physical plant was conducted and medication management was reviewed. Resident were noted to be at their day support program during the inspection so the mid day meal and activities were not observed. Please respond back to your LI with a plan of correction within 10 days of receipt of this notice. If you have any questions please feel free to contact your LI at 540-309-2968.

Violations:

Standard #:	22VAC40-73-170-B
Description:	Based on observations and interviews with staff, the facility failed to ensure that a manager, designated and supervised by the administrator, to assist the administrator in overseeing the care and supervision of the residents and the day-to-day operation of the facility was employed at the facility. EVIDENCE: 1. The facility, who has a shared administrator with another facility, did not have a qualified manager employed as of the day of inspection.
Plan of Correction:	The Administrator met with the owners and Human Resources upon his return and discussed the interviews that were completed for the open facility manager position. The Administrator is setting up second interviews for the three potential applicants and will ensure the position is filled prior to the date noted. In addition, the Administrator will complete an allowed variance request for the new manager as it relates to the previously department approved curriculum for the new manager to ensure they are qualified per standard. The Administrator will ensure that positions of such are filled in the future as quickly as possible per standard.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of resident records, the facility failed to ensure that history and physicals were completed as required prior to residents admission. EVIDENCE: 1. The history and physical dated 6/25/18 in the record for resident 2 does not include a description of allergic reaction to the residents known allergy to Penicillin. The history and physical also does not indicate if the resident is/is not capable of self administering their own medications.
Plan of Correction:	The Administrator reviewed the updated resident history and physical forms and has printed them to be utilized for all future residents. In addition, the ALF Coordinator and Administrator have contacted the noted resident?s primary care physician in order to get more thorough documentation and information on the new physical form. The Administrator, or Assisted Living Coordinator/Program Manager in his absence, will ensure that in the future all current and new residents will have the required admission documentation in their records at all times.
Standard #:	22VAC40-73-390-A
Description:	Based on a review of resident records, the facility failed to update resident agreements when changes in policies and other information occurred. Evidence: 1. The records for residents 1, 2 and 3 were all noted to contain an outdated resident agreement, which did not include information required by the new regulations that were effective 2/1/2018.
Plan of Correction:	The Administrator updated Helton House Inc.?s residential agreements per current standards and is currently reviewing these and implementing with each noted resident. The Administrator, or Assisted Living Coordinator/Program Manager in his absence, will ensure that in the future all current and new residents will have the required admission documentation in their records at all times.
Standard #:	22VAC40-73-400
Description:	Based on a review of resident records and staff interviews, the facility failed to maintain a copy of monthly statements in resident records. EVIDENCE: 1. The records for residents 1, 2 and 3 did not contain a copy of monthly statements. Staff person 1 was unable to obtain the statements during the inspection.
Plan of Correction:	The Administrator located the monthly resident statements for all noted residents, reviewed, and had signed and placed in the resident records at the facility. Monthly residential statements will be completed and in records by the 5th of each month. The Administrator, or Assisted Living Coordinator/Program Manager in his absence, will ensure that in the future all monthly required documentation will be completed and placed in the resident?s records in a timely manner.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record reviews, the facility failed to ensure that individualized service plans (ISPs) were reviewed at least annually. EVIDENCE: 1. The ISP in the record for resident 1 was last reviewed on 4/30/18. 2. The ISP in the record for resident 3 was last reviewed on 2/28/18.
Plan of Correction:	The Administrator located the most current annual service plans for each noted individual and placed them in their resident records at the facility. The Administrator, or Assisted Living Coordinator/Program Manager in his absence, will ensure that in the future all individual service plans will be updated on an annual basis as required and placed in the resident?s records in a timely manner.
Standard #:	22VAC40-73-550-F
Description:	Based on observations, the facility failed to post the rights and responsibilities of residents in at least 14-point type. EVIDENCE: 1. The resident rights and responsibilities posted in the facility on the day of inspection were an old copy from 2007 and were not in 14 point type as required by new regulations that went into effect 2/1/2018.
Plan of Correction:	The Administrator updated the current Resident Rights and Responsibilities to include the required font size 14 in order to post them in the facility. The Administrator, or Assisted Living Coordinator/Program Manager in his absence, will ensure that in the future the Resident Rights and Responsibilities will be updated and posted per standard.
Standard #:	22VAC40-73-930-A
Description:	Based on observations, the facility failed to have an operable signaling device that is easily accessible to the resident in his bedroom or in a connecting bathroom that alerts the direct care staff that the resident needs assistance. EVIDENCE: 1. The facility signaling device was noted to be unplugged and in a kitchen cabinet on the day of inspection.
Plan of Correction:	The Administrator reviewed the signal device policies and procedures with all staff to address the issue of the device being unplugged at the time of the inspection. The system was temporarily unplugged at the time due to the interior of the program being painted. The system is in working condition and was plugged back in prior to the completion of the inspection. The Administrator, or Assisted Living Coordinator/Program Manager in his absence, will check the system weekly to ensure it is maintained and operable. Should the need to unplug the system arise in the future due to similar circumstance, the Administrator, his ALF Coordinator or the program manager, in his absence will utilize a temporary signaling device sufficient to standards for use.