VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hidden Treasures Residential Living
201 Dodge Street
Stuarts draft, VA 24477
(540) 490-1093

Current Inspector: Jessica Gale (540) 571-0358

Inspection Date: Feb. 22, 2021 and March 9, 2021

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 EMERGENCY PREPAREDNESS 63.2 Protection of adults and reporting. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Continue to maintain contact with pharmacy to secure vaccines for residents.

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 2/22/2021 and concluded on 3/09/2021. The administrator was contacted by email to initiate the inspection. The administrator reported that the current census was 10. The inspector emailed the administrator a list of things required to complete the inspection. The inspector reviewed two resident charts including notes and an additional two medication records. Four residents financial assistance procedures were also reviewed. Two staff records plus the record for the new administrator were reviewed that included training, any certification requirements and staff scheduling. The facility has not had a health inspection since 2020 due to Covid. Their kitchen certificate remains current. The fire inspector contacted the facility during this inspection process and plans to come March 11, 2021. A copy will be forwarded to the licensing office upon completion. Additionally emergency drills, health care and pharmacy over site were all submitted by the facility to ensure documentation was complete. Information gathered during this renewal inspection determined non-compliance with two applicable standards or law, and the violations were documented on the violation notice issued to the facility. These were reviewed with the administrator and assistant. Thank you to staff and administration for your patience and assistance during this desk review process. You will be notified by mail regarding your renewal status which is determined by the risk assessment profile generated within the system and following review by the licensing administrator. Should you have additional questions or concerns please call (540) 332-2330 or e-mail this inspector at sharon.deboever@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-80
Description:	The facility assists four residents in managing their personal funds. The facility had verbal but not: 1. Documentation of this request and delegation, signed and dated by the resident and the administrator; 2. Documentation of the resident being given a choice of whether he wishes his funds to be maintained in an individual resident account, or in a single account for the accumulated funds of multiple residents. Either type of account may be interest-bearing. If the account is interest-bearing, the resident must be provided his appropriate portion of the interest; 3.A written accounting of the funds made available to the resident at least quarterly and upon request, and a copy shall also be placed in the resident's record; and 4. Funds are not always readily available to the resident upon request due to the storage of funds and maintenance by the administrator who is not always on site.
Plan of Correction:	The residents do not have the necessary documentation to open individual accounts outside of the facility for each of them. Checks or cash is received and maintained in separate envelopes with a separate accounting for each individual including maintaining receipts. The facility will secure written permission from each resident regarding maintenance of funds. When cash is given directly to a resident they will sign for it just as receipts are maintained when they ask a staff to make a purchase on their behalf. The preference is resident's shop for themselves but with Covid that has not been an option. The administrator will also begin reviewing the accounts with residents upon requests and at a minimum of quarterly provide a written accounting to them as well as their POA. Locating funds outside of the administrator's office will be discussed with staff and a plan developed to ask residents what funds they would like available in the administrator's absence. As the full money management policy and procedure is developed it will be forwarded to licensing for review.
Standard #:	22VAC40-73-650-A
Description:	Based on a review of resident's medication administration and physician orders, resident C did not have an order to self administer a B-12 injection.
Plan of Correction:	Physician was contacted immediately upon exit review and order was received within 24 hours. Copy was forwarded to the licensing office. Resident has always self administered that injection even prior to moving to the facility and at their previous facility. It is understood that moving forward any medication allowed to be self administered by a resident must have a physician's order for such. All staff assisting with medication will be responsible for monitoring and maintaining future compliance.