809 Hopeman Parkway
Waynesboro, VA 22980
Current Inspector: Laura Lunceford (540) 219-9264
Inspection Date: Feb. 22, 2021 , Feb. 23, 2021 and Feb. 24, 2021
Complaint Related: No
- Areas Reviewed:
22VAC40-73 GENERAL PROVISIONS
22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES
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
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.
- Technical Assistance:
Discussions occurred with the administrator on the following:
1) The Acetaminophen for resident D expires this month (February 2021).
2) The Polyethylene Glycol order for resident A did not include a timeframe.
3) Recommended adding a column on the fire drill log for corrective actions taken.
4) Ensure the response letter regarding corrective actions taken to the resident council is dated as to when it was submitted to the council.
5 Recommended providing an in-service for all registered medication aides on the procedures for documenting insulin administration as there was no consistency. Although all required information was documented on the medication administration records (MARs), the information was being documented in different places.
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 2/22/21 and concluded on 2/24/21. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 27. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed three resident, three staff and two contract staff records. Selected sections of six additional resident and five staff records were also reviewed. The activities calendar, menu, staff schedules, administrator's schedule, fire drills, dietary/medication/health care oversight reviews, February medication administration records, physicians' orders, as-needed (PRN) medications/expiration dates, all criminal record checks for all current employees hired since the last inspection, as well as other documents, to ensure documentation was complete. A virtual inspection and tour were also conducted with this desk review. 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.
Standard #: 22VAC40-73-350-B Description: Based upon documentation and an interview, the facility failed to ensure one of five residents' sex offender registry checks was completed prior to admission.
1) The sex offender registry check for resident B (admitted 5/27/20) was dated as completed on 5/28/20.
2) On 2/24/21, the licensing inspector (LI) interviewed the administrator who stated the sex offender registry check was not completed prior to admission.
Plan of Correction: Sex offender registry check was completed on 5/28/20 for resident B. All 26 resident files have been reviewed and were in compliance. Administrator will complete sex offender registry checks upon completion of face to face interviews, prior to admission, for future residents in order to ensure compliance. Administrator will complete the sex offender registry check prior to each new resident's move in.
Standard #: 22VAC40-90-40-B Description: Based upon documentation and an interview, the facility failed to ensure one of five criminal record checks (CRCs) was obtained within 30 days of employment.
1) The CRC for staff A (hired 8/14/20) was completed on 9/25/20.
2) On 2/24/21, the LI interviewed the administrator who stated the CRC was not completed within 30 days of staff A being hired.
Plan of Correction: Criminal record check for staff A was received on 9/25/20. The Virginia State Police was called by administrator on 2/25/21 to advise of compliance issue. They advised due to the pandemic and the postal service delays, they can not guarantee timeframe for criminal record checks through the mail process. Administrator initiated online account set up to avoid compliance issues. All other staff hired were in compliance. Administrator will mail criminal record check form on date of hire until online account is set up.
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.