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: June 3, 2020

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 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

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 on 6/3/2020 and concluded on 6/4/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 10. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, staff schedules, fire and health inspections, health care over sight, fire drills and dietitian reports submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on a review of staff records, the facility failed to ensure all staff received 2 hours of annual training in infection control. EVIDENCE: 1. The training records for staff persons 1 and 2 do not have documentation that these individuals received at least 2 hours of training annually in infection control and prevention.
Plan of Correction:	The Administrator and Human Resource Coordinator reviewed the current OSHA/Infection Control/Prevention curriculum being utilized, along with current written acknowledgement forms and training records to ensure all meet current standard. The Administrator and Human Resource Coordinator will revise the current training records listing, training curriculum description, and staff written acknowledgement forms to ensure that all related trainings conducted are detailed and listed separately to indicate the precise number of hours trained for each required topic per standard. In addition, a record of all current COVID-19 related or other CDC, VDH, VADSS provided resources, trainings, or guidelines that have been completed since the beginning of the epidemic will be added to each employee?s training records.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, the facility failed to ensure that staff submitted the results of a tuberculosis assessment on or within seven days prior to the first day of work. EVIDENCE: 1. The record for staff person 2, employed on 2/4/2020, did not receive their results of a tuberculosis risk assessment until 2/7/2020.
Plan of Correction:	The Administrator reviewed the noted standard along with the noted staff?s record. The Administrator and Human Resource Coordinator will implement specific dates on all employee records the following moving forward regarding hire date, training start date (which is held and completed at a location other than the facility, and specific ?first day of work? in the facility to ensure noted standard is followed and evidenced via documentation in the staff record correctly. The Administrator will ensure that all new employee?s have received TB test results and filed in the employee record prior to their official first day of work in the facility per standard.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The record for resident 1 has documentation on a fall risk rating dated 1/1/20 that the resident is a risk for falls. A physical examination dated 3/25/2020 has documentation of a order for physical and occupational therapy and for a 1800 to 200 calorie diet. The comprehensive ISP dated 1/16/20 does not address these identified needs. 2. The record for resident 2 has a physical examination dated 3/25/20 with a order for a regular diet. The comprehensive ISP dated 1/16/20 is inconsistent as it has the resident on a low cholesterol, no added salt diet.
Plan of Correction:	The Administrator and ALF Coordinator reviewed the noted standard and all noted resident records. Upon review and contact with Primary Care Physician, the noted resident?s physical on hand is incorrect and is being revised and updated to reflect the accurate diet and current, if needed, order for PT/OT assessment and fall risk assessment. The individual?s ISP will be updated and corrected upon receipt of the revised physical examination record and filed accordingly to ensure all needs are addressed as required. The Administrator will review all new resident physical examinations upon receipt and prior to the placing in the individual?s record to ensure all areas of need, diets, or other related orders are accurate and addressed per standard. The Administrator and ALF Coordinator will review all resident ISP?s quarterly, unless otherwise necessary due to added need or change in support/service delivery, to ensure all areas of care needed are addressed and correct per standard.