VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living Communities
201 & 202 Lillian Lane
Lynchburg, VA 24502
(434) 385-5102

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: Aug. 28, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 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 08/28/2020 and concluded on 09/09/2020. A complaint was received by the department regarding an allegation that the facility's special care unit was understaffed. The Administrator was contacted by telephone to conduct the investigation and a virtual inspection took place on 08/28/2020. 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 #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on document review and staff interview, the facility failed to ensure that, except during night hours when 20 or fewer residents are present, at least two direct care staff members are awake and on duty at all times in each special care unit (SCU) who are responsible for the care and supervision of the residents and for every additional 10 residents, or portion thereof, at least one more direct care staff member shall be awake and on duty in the unit. EVIDENCE: 1. Interview with staff 1 revealed that the census for 08/28/2020 was 49 residents in care and that the ?Employee Time Cards? were for those direct care staff that worked in the SCU on 08/28/2020. Based on the census there should have been five direct care staff on duty at all time. 2. The DAYBREAK 1ST (shift) staff schedule showed that on 08/28/2020 there were seven direct care staff scheduled to work the first shift in the SCU; however, the facility?s ?Employee Time Cards? for staff that worked in the facility?s SCU on 08/28/2020 showed that only four staff were on duty during the following times: from 7:43AM through 8:30AM (staff 2, 3, 4 and 5); from 12:00PM through 12:15PM (staff 6, 7, 8 and 9); and from 2:30PM through 3:00PM (staff 2, 6, 7 and 9). 3. The DAYBREAK 2nd (shift) staff schedule showed that on 08/28/2020 there were six direct care staff scheduled to work the second shift in the SCU; however, the facility?s ?Employee Time Cards? for staff that worked in the facility?s SCU on 08/28/2020 showed that only four staff were on duty during the following times: from 8:30PM through 8:45PM (staff 2, 10, 11 and 12); from 9:00PM through 9:15PM (staff 2, 11, 12 and 13); and from 9:30PM through 10:00PM (staff 2, 10, 12 and 13). The time cards showed that only 3 staff were on duty from 8:45PM through 9:00PM (staff 2, 11 and 12). 4. The DAYBREAK 3rd (shift) staff schedule showed that on 08/28/2020 there were five direct care staff scheduled to work the third shift in the SCU; however, the facility?s ?Employee Time Cards? for staff that worked in the facility?s SCU on 08/28/2020 showed the following: from 4:00AM through 4:15AM there were only four staff on duty (staff 4, 10, 13, and 14); from 4:15AM through 4:30AM there were only two staff on duty (staff 10 and 13); and from 4:30AM through 4:45 AM there were only three staff on duty (staff 10, 13 and 15).
Plan of Correction:	The Executive Director (ED) has investigated the dates and times of the staffing discrepancies identified in this violation report and has conducted a root cause analysis to develop a plan to maintain SCU staffing levels in accordance with this regulation. SCU direct care staff will remain on duty and in the unit during his or her shift (see attachment A). Payroll system will no longer automatically deduct the 30-minute lunch break. If a staff member needs to leave the unit for any reason, he or she will notify the designated staff member in charge and remain on the unit until coverage is present. SCU Staff will be in-serviced on the unit on-duty policy and process that they must undertake if they need to leave the SCU. (See attachment B) Training will be completed by September 25, 2020 The facility is aggressively recruiting and on-boarding direct care staff and has developed a staff incentive program to encourage staff to fill scheduling vacancies. The ED or designee will review staff punch sheets daily and staff non-compliance will be addressed accordingly. The ED will also verify staff changes are made to the master schedule when required