VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Chastain Home for Gentlewomen
370 Mountain Rd.
Halifax, VA 24558
(434) 476-6057

Current Inspector: Cynthia Jo Ball (540) 309-2968

Inspection Date: Nov. 9, 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 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 11/9/2020 and concluded on 11/10/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 8. 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 and facility fire drill logs submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-200-B
Description:	Based on a review of resident records, the facility failed to ensure that direct care staff provided special health care service needs within the scope of their practice and training. EVIDENCE: 1. The record for resident 1 has documentation of a physician order dated 9/15/2020 for Xeroform Dressings to a wound 3 times a week. The order has directions for Home Health to complete the treatment twice a week and for the facility Administrator to complete the treatment once a week. Interview with staff person 1 indicated that the treatment was completed on 9/15/2020 by a staff person of the facility who was practicing outside of their scope of practice and training.
Plan of Correction:	On November 9th, the healthcare provider was notified, and resident 1 will be receiving skilled nursing care three times a week by their trained licensed professionals,
Standard #:	22VAC40-73-260-A
Description:	Based on a review of staff records, the facility failed to ensure that all direct care staff members received certification in first aid within 60 days of the day of employment. EVIDENCE: 1. The record for staff person 2, hired on 5/12/20 does not contain documentation that the employee has received certifications in first aid since the date of their employment.
Plan of Correction:	On November 13th, 2020 staff person two received their certification in First Aid.
Standard #:	22VAC40-73-440-D
Description:	Based on a review of resident records, the facility failed to ensure that uniform assessment instruments (UAI) were completed as required. EVIDENCE: 1. The UAI dated 10/30/20 in the record for resident 1 has documentation that the resident is disoriented to some spheres some of the time but does not have documentation as to what spheres are affected.
Plan of Correction:	The UAI for resident one has been corrected, and documentation is listed as to what spheres are affected.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISPs). EVIDENCE: 1. The history an physical dated 7/20/20 in the record for resident 2 has documentation that the resident wears bilateral hearing aids. Also the uniform assessment instrument dated 8/14/20 for resident 2 has documentation that eh resident requires mechanical assistance with transferring. The ISP dated 8/10/20 does not address these identified needs.
Plan of Correction:	The ISP for resident two has been corrected and now has listed that resident two wears a bilateral hearing aid. The UAI for resident two?s use of mechanical assistance needed for transfer is reflected on their ISP.
Standard #:	22VAC40-73-470-B
Description:	Based on a review of resident records, the facility failed to ensure that resident's needs for skilled nursing treatments within the facility were met. EVIDENCE: 1. The record for resident 1 has documentation of a physician order dated 9/15/2020 for a Xeroform Dressing wound care to be completed 3 times a week, twice a week by Home Health and once a week by the facility Administrator. Per an interview with staff person 1, the wound treatment for resident 1 has only been completed twice a week by a Home Health and that the third treatment weekly was not being completed.
Plan of Correction:	On November 9th, the healthcare provider for resident 1 was contacted and the residents needs will be met. The healthcare provider will ensure that resident one receives skilled nursing care (wound Care) from their trained, licensed staff.
Standard #:	22VAC40-90-30-B
Description:	Based on a review of employee records, the facility failed to ensure that a sworn statement or affirmation was completed prior to employment. EVIDENCE: 1. The record for staff person 2, hired on 5/12/20 has documentation that the sworn statement or affirmation was not completed until 5/18/20, 5 days after the date of hire.
Plan of Correction:	The Chastain Home will ensure when hiring a new employee to adhere to the Standards for Assisted Living 2VAC40-90-(BC2)-30-B, sworn statement or affirmation will be completed prior to employment.