VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Grayson House
110 Bedwell Street
Independence, VA 24348
(276) 773-3525

Current Inspector: Crystal Mullins (276) 608-1067

Inspection Date: Oct. 9, 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

Comments:

Two licensing inspectors conducted an unannounced license renewal inspection at Grayson House on 10/09/2019. The inspection began at 2:00 pm and concluded at 4:55 pm. A tour of the building and grounds was conducted. Residents were interviewed. Resident and staff interactions were observed. The evening medication pass was observed and Medication Administration Records were reviewed. Resident and staff files were reviewed. The facility is licensed to provide care to 10 residents, and 10 residents were found to be in care at the time of the inspection. Required postings and the previous inspection was observed to be in place. An exit meeting was conducted with the administrator and other staff on 10/09/2019 and at that time the opportunity was given to find items that were not readily available in the records. As a result of this inspection, three violations are being cited. A corrective action plan should be developed addressing the steps to correct the noncompliance of each standard, measures to prevent the reoccurrence, and the person(s) responsible for implementing each step and/or monitoring and prevention measures. The description of each action to be taken for each violation along with the date to be corrected must be returned to this office signed and dated within 10 calendar days of receipt (10/20/2019). If you have any questions please feel free to contact your inspector at 276-608-1067. Thank you for your cooperation and assistance during this inspection.

Violations:

Standard #:	22VAC40-73-50-A
Description:	Based on documentation review, the facility failed to provide disclosure to the resident on a form developed by the department. EVIDENCE: 1. Resident # 2 was admitted to the facility on 10/01/2019. The facility included a disclosure statement in Resident #2's file, however, it was not the most recent form developed and adopted by the department which went into effect 03/01/2019.
Plan of Correction:	The outdated disclosure statement in the file of Resident #2 has been replaced with the most recent disclosure statement form developed and adopted by the department. The administrator will ensure the most recent disclosure statement will be utilized for all future residents admitted to the facility. [sic]
Standard #:	22VAC40-73-380-A
Description:	Based on review of resident records, the facility failed to ensure all personal and social data was obtained prior to or at the time of admission for one resident in a population of eight. EVIDENCE: 1. Resident # 2 was admitted to the facility on 10/01/2019. The marital status on his personal and social data sheet was left blank.
Plan of Correction:	All residents' personal & social data forms will be reviewed by the administrator to ensure the document has been completed in its entirety. [sic]
Standard #:	22VAC40-73-430-J
Description:	Based on documentation review and review of resident files, the facility failed to issue a final statement of account and return property within 60 days of the date of discharge. EVIDENCE: 1. Resident #1 was discharged from the facility on 01/23/2019. There was no final statement of account found in his file. Resident #1's file still contained two Medicare cards, two Anthem insurance cards, and his voter registration card.
Plan of Correction:	An account and return property statement has been mailed to the guardian of Resident #1, including Resident #1s Medicare, insurance & voter registration cards. The administrator will ensure future discharged residents receive an account and return property statement and all personal property, within 60 days of discharge from the facility. [sic]