VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Starling View Manor #1
301 Starling Avenue
Martinsville, VA 24112
(276) 632-0820

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: May 28, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 monitoring inspection was initiated on 5/26/2020 and concluded on 5/28/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 7. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records, resident roster, staff roster, staff schedule, facility health care oversight, fire and emergency drills, health department inspection, dietitian oversight, and activity calendar 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.

Violations:

Standard #:	22VAC40-73-250-D
Description:	250-D Based on record review, the facility failed to ensure that each staff person on or within seven days prior to the first day of work at the facility shall submit the results of a risk assessment, no older than 30 days, documenting the absence of tuberculosis (TB) in a communicable form as evidenced by completion of the current screening form published by the Virginia Department of Health or a form consistent with it. EVIDENCE: 1. Staff 1 was hired on 6/12/2019; however, her record contained an initial TB risk assessment that was completed on 4/16/2019.
Plan of Correction:	The Administrator and/or the Office Manager will make sure all TB-test are no older than 30 days from their first day of work. This will be done within the hiring process.
Standard #:	22VAC40-73-450-C
Description:	450-C Based on record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include: the description of identified needs and date identified based upon the (1) UAI; (2) admission physical examination; (3) interview with resident; (4) fall risk rating, if appropriate; (5) assessment of psychological, behavioral, and emotional functioning, if appropriate; and (6) other sources. EVIDENCE: 1. The ISP for resident 2 did not indicate that the resident uses an ambulatory assistive device; however, the use of such device is indicated on the resident?s fall risk rating. 2. Interview with staff 3 verified that resident 2 sometimes uses a leg brace for mobility.
Plan of Correction:	The facility will check all ISPs to ensure that they are in line with UAI, physical examinations, interviews of residents, fall risk assessments, and mental assessments. The ISPs will be reviewed monthly and updated accordingly.