VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living
7080 Brooks Farm Road
Mechanicsville, VA 23111
(804) 746-7370

Current Inspector: Shelby Haskins (804) 305-4876

Inspection Date: May 26, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMISSION, RETENTION, AND DISCHARGE OF RESIDENTS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated and concluded on 5/26/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 57 residents. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four staff records,health care oversight, the staff schedule, fire and health inspection reports,etc.submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Criminal background checks were reviewed since the last inspection and all were in compliance. The facility has 10 calendar days from receipt of the inspection reports to complete a plan of correction, sign the inspection reports and return them to the licensing office. A copy of the inspection reports shall be retained to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS website within 15 calendar, regardless of whether the plan of correction is completed. Just writing the word ?corrected? is not acceptable. The plan of correction shall include the following: (1) Step(s) the facility will take to correct the violations cited; (2) Measures that will be put in place to prevent reoccurrence of each violation; (3) Person(s) responsible for implementation and monitoring of preventive measures; and (4) Date by which each violation will be corrected. personnel records were reviewed since the last inspection for criminal history record reports and all were in compliance.

Violations:

Standard #:	22VAC40-73-1100-A
Description:	Based on a desk review for four residents, the order of priority was not documented in securing approval for placement of one resident in a safe, secure environment. Evidence: The adult child for resident # 2 signed the Approval for Placement In Special Care Unit form on 1/2020, the form did not document why written approval was not obtained from each individual higher on the list of priority.
Plan of Correction:	A written approval for placement was signed and received by POA (power of attorney) on 12/18/2019 with permission by the adult child. The administrator had not included the permission form with the desk review inspection. We do have it in the resident's chart. The administrator or designee will ensure all documents are included in the next inspection.
Standard #:	22VAC40-73-1110-B
Description:	Based on a desk review for four residents on 5/26/2020, the licensee, administrator, or designee did not perform an annual review of the appropriateness of one resident's continued residence in the special care unit. Evidence: The last documented review of appropriateness for continued placement in a special care unit for resident # 4 was dated 12/20/2018 based on the desk review.
Plan of Correction:	The review for appropriateness was not obtained on this past resident that is deceased. The Executive Director or designee will ensure that a yearly review will be completed at the yearly review with the resident/POA and placed in the resident's record. This will ensure that the yearly review will be complete.
Standard #:	22VAC40-73-325-B
Description:	Based on a desk review for four resident on 5/26/2020, a fall risk rating was not completed after a fall for one resident. Evidence: The review for resident # 4 documented a fall on 4/24/2020. there was no documentation of a review or update of the fall risk rating after the fall.
Plan of Correction:	RCD (Resident Care Director) was retrained By home office and will ensure that all post falls will be reviewed by the RCD and will conduct a fall review . The RCD will then update ISP(individualized service plan) and the resident's chart. The Executive Director will sign the incidents after each fall and ensure that all updates have been made.