VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Starling View Manor #1
301 Starling Avenue
Martinsville, VA 24112
(276) 632-0820

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: Nov. 30, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-90 The Criminal History Record Report

Technical Assistance:

380, 440, 650

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 11/30/2020 and concluded on 12/2/2020. The facility representative and the administrator were contacted jointly by telephone to initiate the inspection. The facility representative reported that the current census was seven. The inspector emailed the facility representative and the administrator a list of items required to complete the inspection. The inspector reviewed two resident records, two staff records, the Sworn Disclosure Statement and Criminal Record Report for all new staff members, resident roster, staff roster, staff schedule, facility health care oversight, fire and emergency drills, health department inspection, and dietitian oversight submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-73-210-F
Description:	210-F Based on record review, the facility failed to ensure that at least two of the required hours of annual training shall focus on infection control and prevention. EVIDENCE: 1. Staff 1, hired 1/05/2017, only had one hour of infection control and prevention training from 1/5/2019 ? 1/4/2020. 2. Interview with staff 4 concluded that staff 1 did not receive all required infection control and prevention training during that time period.
Plan of Correction:	Starting this month, all required training shall be given, including infection control.
Standard #:	22VAC40-73-450-C
Description:	450-C Based on record review, the facility failed to ensure that the comprehensive individualized service plan (ISP) shall include a description of identified needs and date identified based upon the uniform assessment instrument and the fall risk rating. EVIDENCE: 1. The ISP for resident 2, dated 7/17/20, does not indicate her need for pull-ups for bladder incontinence as indicated by her public pay UAI, dated 7/25/20. 2. Interview with staff 4 indicated that resident 2 does use pull-ups for bladder incontinence. 3. The ISP for resident 1, dated 3/06/20, does not include the fall risk rating. 4. The fall risk rating for resident 1, dated 2/03/2020, assessed the resident as a low to moderate fall risk. 5. The ISP for resident 2, dated 7/17/20, does not include the fall risk rating. 6. The fall risk rating for resident 2, dated 1/24/2020, assessed the resident as a low to moderate fall risk.
Plan of Correction:	All ISPs will be reviewed and all required needs are addressed.
Standard #:	22VAC40-90-40-B
Description:	22VAC40-90-40-B Based on record review, the facility failed to ensure that the criminal history record report shall be obtained on or prior to the 30th day of employment for each employee. EVIDENCE: 1. Documentation for staff 3 indicated a hire date of 7/08/2020, and the CRC results were dated 8/28/2020.
Plan of Correction:	Any new employee will not start job until Criminal Background Check is back, starting immediately.