VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carriage Hill Retirement
1203 Roundtree Drive
Bedford, VA 24523
(540) 586-5982

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Aug. 10, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-80 COMPLAINT INVESTIGATION.

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 complaint inspection was initiated on 08/10/2020 and concluded on 08/20/2020 in conjunction with local adult protective services. A complaint was received by the department regarding allegations in the areas of resident accommodations and related provisions pertaining to a resident's mail being opened. The Administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the Administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegation of non-compliance with standards or law, and violations were issued. Any violations not related to the complaint but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-800-C
Complaint related:	Yes
Description:	Based on documentation review, resident interview and staff interview, the facility failed to ensure that mail was not opened by staff except upon request of the resident and in his presence or written request of the legal representative. EVIDENCE: 1. The facility?s document entitled ?PERSONAL BELONGINGS? states the following: ?5. Discourage Residents/Responsible Persons from bringing or sending personal items (via USPS or in-person) of significant value to the Community to reduce risk of loss or damage. Staff has the right to inspect any suspicious package?. 2. ?BEDFORD POLICE DEPARTMENT INCIDENT REPORT?, dated 08/01/2020 at 5:07:36 PM, stated the following: ?I (Collateral 2) spoke to (staff 2) who handles (resident 1). (Staff 2) stated they check all packages for things the guests cannot have such as medicines and certain banned items that the policy of the Carriage Hill Homes enforced and allows staff to open suspected packages that might have these items. They will shake the boxes and if it sounds like a bottle of medicine or something of a chemical they open and verify its not harmful to the guest. In the past (resident 1) had a real phobea of people touching her things and time passed since she?s been here three years and the phobea seemed to fade a bit but, until today they opened two of her items and found one contained bird seed and the other some beauty product and they had been given to (resident 1) without any further delay?. 3. Interview with resident 1 verified that on 08/01/2020 her two packages, bird seed and graham crackers, were opened without her being present by staff 2. Resident 1 stated that this is not the first time her packages have been opened by staff and noted that some staff who ?work the front desk? started opening her packages 5-6 months ago without her being present. 4. Interview with staff 2 verified that on 08/01/2020 she opened two packages that were delivered for resident 1 when the resident was not present; first package contained a pack of oreos and a large pack of crackers and the second package contained bird seed. Staff 2 stated that the two packages were sitting at the nurses? station and staff 2 saw them, picked them up to take to resident 1, but then heard something ?moving around? which indicated to staff 2 that there could be medication in the two packages. Staff 2 stated that resident 1 was upset with this but staff 2 informed resident 1 that ?we have to open your packages because we thought pills were in there?. Staff 2 stated that ?As far as I know we have always had a policy regarding opening residents? packages if we feel they contain medications or something they should not have?.
Plan of Correction:	1. Updated facility document titled "Personal Belongings" by omitting the final sentence which stated, "Staff has the right to inspect any suspicious package". 2. Staff will be in-serviced on 22VAC40-73-(7)-800-C Dated to be corrected: 9/7/2020