VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Lady of the Valley
650 N. Jefferson St
Roanoke, VA 24016
(540) 345-5111

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: March 1, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 EMERGENCY PREPAREDNESS

Technical Assistance:

325-B, 440-C, 480-E

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 3/1/2021 and concluded on 3/2/2021. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 56. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed four resident records, four 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 #:	22VAC40-73-450-D
Description:	450-D Based on record review, the facility failed to ensure that when hospice care is provided to a resident, the ALF and the licensed hospice organization shall communicate and establish an agreed upon coordinated plan of care for the resident. The services provided by each shall be included on the individualized service plan (ISP). EVIDENCE: 1. The ISP for resident 4, dated 1/15/2021, indicated that the resident is receiving palliative services and end of life care by Good Samaritan hospice; however, the ISP did not indicate which services that hospice was providing.
Plan of Correction:	1. The ISP for resident #4 was updated to indicate the services established in the contract with Good Samaritan Hospice. 2. All resident service plans indicating contracted services were audited to inspect for individualized service needs. 3. The DON/Designee will audit service plans monthly to ensure individualized needs are explained thoroughly. 4. The Administrator/Designee will ensure compliance.
Standard #:	22VAC40-73-970-A
Description:	970-A Based on record review, the facility failed to ensure that fire and emergency evacuation drills provided for each shift in a quarter were not conducted in the same month. EVIDENCE: 1. The facility?s fire and emergency drill documentation indicated that the past three fire and emergency drills occurred on 2/19/2021 on 3rd shift, 1/28/2021 on 2nd shift, and 12/23/2021 on 3rd shift. 2. Interview with staff 5 indicated that a 1st shift fire and emergency drill occurred on 1/25/2021; however, this occurred during the same month as the 2nd shift drill.
Plan of Correction:	1. The facility completed four fire drills within the last quarter. The maintenance team was in-serviced on fire drill regulations and conducting monthly drills on a different shift each month. 2. The Facilities Director/Designee will schedule planned drills in advance to ensure a different shift is covered each month within the quarter. 3. The Facilities Director/Designee will audit the fire and safety manual quarterly to ensure drills are conducted timely. 4. The Administrator/Designee will ensure compliance.