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: Nov. 4, 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 SANCTIONS.

Technical Assistance:

To ensure the facility has a thorough understanding of the standards, the LI and the Administrator, Resident Care Director and the Vice President of Quality Services had a discussion regarding 450 C & 970 A.

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 11/04/2020 and concluded on 11/05/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 93; 47 of those resident reside in the facility Special Care Unit (SCU). The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 5 resident records, 5 staff records, staff schedule for past two weeks, medication review and fire and emergency plan submitted by the facility to ensure documentation was complete. The LI also had a discussion with the Administrator, Resident Care Director and the Vice President of Quality Services regarding standards 22VAC40-90-40-B & 640 A to ensure a thorough understanding. 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 #:	22VAC40-73-260-A
Description:	Based on staff record review, the facility failed to ensure that direct care staff who do not have current certification in first aid received certification in first aid within 60 days of employment. EVIDENCE: 1. The record for staff 3, date of hire 04/01/2019, did not contain documentation that staff 3 had current first aid certification when hired or that first aid was completed within 60 days of the start date of staff 3.
Plan of Correction:	What: Staff 3?s CPR training which was completed timely, did not contain first aid training. How: Staff 3 will take first aid at the next scheduled class, 11/17/2020. Executive Director conducted a training on 11/6/2020 with the Business Office Manager showing her what to look for on a CPR / First Aid certification to ensure both elements are contained. (Attachment A). Executive Director reviewed all other care staff's files and all care staff meet the regulations for CPR and First aid at this time. Heritage Green has a monthly class and several staff are scheduled to take the 11/17/2020 class to meet the requirement to have CPR and First aid within their first 60 days. Ongoing: Business Office Manager or designee will review the CPR / First Aid certificates upon hire and renewal to ensure they contain both elements and are timely. Business Office Manager or designee will update the spreadsheet with the dates of the certification taken and expiration, reviewing that with the Executive Director at least monthly. Monthly QA audits will be completed by the Business Office Manager and reviewed at the Quarterly QA meeting.
Standard #:	22VAC40-73-270-1
Description:	Based on review of staff and resident records and staff interview, the facility failed to ensure training prior for staff in assisted living facilities that accept, or have in care, residents who are or who may be aggressive behavior included demonstration in self-protection and in the prevention de-escalation of aggressive behavior. EVIDENCE: 1. The resident roster provided by staff 6 showed that the facility has 12 residents in care that have aggressive behavior. 2. The record for staff 1, date of hire 09/24/2020, did not contain documentation that staff 1 had demonstration in dealing with residents with aggressive behavior prior to working with those residents. 3. Interview with staff 6 confirmed that staff 1 did not complete the required demonstration portion of the training.
Plan of Correction:	What: Staff 6 completed the online aggressive behavior training, but not the in-person demonstration portion. How: Staff will continue to have the online aggressive behavior training. Staff will receive the additional in-person demonstration portion conducted by a qualified health professional as part of new hire training and annually. Staff 6 and any other recent hires will receive the additional in-person demonstration portion by 11/30/2020. The aggressive behavior training and demonstration checklist has been reviewed by DSS and will be used for training and documentation of training. (Attachment B) Ongoing: Business Office Director or designee will review all new hire charts at 30 days to ensure they have completed the demonstration portion of aggressive behavior training. Monthly QA audits will be completed by the Business Office Director and reviewed at the Quarterly QA meeting.