VIRGINIA DEPARTMENT OF SOCIAL SERVICES

SEARCH Group Home, Inc.
5742 N. Main Street
Mount jackson, VA 22842
(540) 477-2808

Current Inspector: Jeffrey Marnien (540) 571-0189

Inspection Date: Sept. 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 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

Technical Assistance:

The following areas were reviewed with the administrator: 1) Recommended using the model orientation form as the facility form used for the new staff did not specify the two types of incident reporting. 2) Ensure each medication/treatment on the medication administration records (MARs) has a specific diagnosis. Three residents' MARs were reviewed and one medication did not include a diagnosis - the Epinephrine Pen for resident C. An order for Robafen did not include the specific dose (15 to 30ml). 3) Administrator gave the inspector a copy of the updated written assurance form. 4) Reviewed process used to ensure all as-needed (PRN) medications were labeled. NOTE: One medication (Migrelief) was not labeled with the resident's name.

Comments:

An unannounced monitoring inspection was conducted on 9/30/19 from approximately 8:40 am to 6:40 pm. A tour was immediately conducted of the interior and exterior of the facility. The facility was clean and free from any foul odors and all required postings were in place. Upon arrival there were no residents in care and one staff on duty. There was one new admission and two discharges since the last inspection. There were two new staff hired since the last inspection but only one was still employed. Upon departure there were seven residents and three staff present. Medication administration observations were completed with three residents. The medication administration records, physicians' orders and medications were reviewed. The one new resident, two discharge, two contract staff and the two new staff records were reviewed. Selected sections of five additional records for residents and staff were also reviewed. Individual interviews were conducted with residents and staff. There were no family members available to interview. The areas of noncompliance included staff tuberculin skin tests/assessments, training on residents with aggressive behaviors, annual review of the sex offender registry information, health care oversight and expiration dates of items in the van first aid kit. Staff answered all questions and obtained all information requested. Thank you for your assistance and cooperation during this inspection.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based upon documentation and an interview, the facility failed to ensure one of two new staff had an initial tuberculin (TB) skin test/assessment completed prior to the first day of work. Evidence: 1) The only TB skin test/assessment on file for staff F (hired 12/18/18) was completed on 1/14/19. 2) On 9/30/19, the licensing inspector (LI) interviewed the administrator who stated this was the only TB skin test/assessment completed and on file for staff F.
Plan of Correction:	TB skin tests/assessments will be completed before any new staff begin working. TB skin tests/assessments will be given to new staff with all background paperwork, etc. Administrator will make certain TB results are in all new staffs' records prior to scheduling any hours.
Standard #:	22VAC40-73-270-4
Description:	Based upon record reviews and an interview, the facility failed to ensure six of seven staff completed training on residents with aggressive behaviors. Evidence: 1) Staff A, B, C, E, F and I did not have documentation of training on residents with aggressive behaviors since the last inspection. 2) According to the staff training records and an interview with staff A, the last time aggressive training was provided to staff was on 10/12/17. 2) On 9/30/19, the LI interviewed staff A who stated annual training on aggressive behaviors had not been provided since October 2017.
Plan of Correction:	Administrator was not aware aggressive training was required for all staff. Administrator will see that all staff complete aggressive behavior training annually.
Standard #:	22VAC40-73-350-C
Description:	Based upon record reviews and an interview, the facility failed to ensure five of the six residents'records reviewed had documentation of annual reviews of the sex offender registry information. Evidence: 1) Residents A, B, D, E and F did not have documentation of an annual review of the sex offender registry information. 2) On 9/30/19, the LI interviewed the administrator who stated the annual reviews of the sex offender registry had not been completed with the residents.
Plan of Correction:	In the future, the administrator will have an annual review of sex offender registry information with each resident during annual review of Rights and Responsibilities of Residents.
Standard #:	22VAC40-73-490-D
Description:	Based upon documentation and an interview, the facility failed to ensure the health care oversight included a list of residents reviewed. Evidence: 1) The health care oversight form was completed; however, it did not indicate or include a list of the residents reviewed during each oversight completed since the last inspection. 2) On 9/30/19, the LI interviewed the administrator who stated the health care oversight contract staff did not include a list of the residents that were reviewed during each quarter the health care oversight was completed
Plan of Correction:	Administrator has now provided a list of residents to health care oversight staff to check off the names of the residents reviewed. The list will include a statement that the residents' names who are checked were reviewed during the oversight and the person completing the oversight will sign and date the list and keep it attached to the health care oversight form. The list will remain attached to the health care oversight form. The administrator will ensure compliance.
Standard #:	22VAC40-73-980-C
Description:	Based upon observations, the facility failed to check the expiration date on the antiseptic ointment in the facility van first aid kit. Evidence: On 9/30/19, the LI checked the van first aid kit and observed the antiseptic ointment expired December 2018.
Plan of Correction:	Expiration date was mistakenly read as 12/19. Administrator replaced the expired ointment on 9/30/19. This task will be added to the monthly check off sheet that includes checking smoke detectors and flashlight batteries which is completed after each fire drill.