VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hughes Home
100 Caroline Street
Fredericksburg, VA 22401-6104
(540) 373-4100

Current Inspector: Sarah Pearson (540) 680-9469

Inspection Date: July 13, 2020

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 EMERGENCY PREPAREDNESS

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 complaint inspection was initiated on July 5, 2020 and concluded on October 1, 2020. A complaint was received by the department regarding allegations in the areas of emergency preparedness and resident care. The administrator was contacted by telephone to conduct the investigation. The licensing inspector emailed the administrator a list of documentation required to complete the investigation. The evidence gathered during the investigation supported the allegations of non-compliance with standards or law. No violations were issued as the facility had already taken corrective action.

Violations:

Standard #:	22VAC40-73-100-F
Complaint related:	Yes
Description:	The licensee failed to follow recommendation by the Virginia Department of Health, VDH, to prevent or control transmission of an infectious agent in the facility. VDH advised against co-mingling of residents during meals and activities in order to reduce the spread of COVID -19. Evidence: Guidance from VDH to reduce the spread of COVID-19 advises against the co-mingling of residents during meals and activities. The facility verified in an email dated May 29, 2020 that co-mingling of residents was occurring daily during meal time and activities. VDH notified the DOLP on July 13, 2020 that the facility was not following the VDH guidance to develop a ?hot unit? that would house all residents that had tested positive for COVID-19 and a ?warm unit? for any resident suspected to have COVID-19. VDH was also concerned that residents that were not demonstrating an acute illness, but suspected to have COVID19, were being transferred to the hospital, unnecessarily. The facility would not accept the resident back, if they did test positive for COVID-19.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-40-A
Complaint related:	Yes
Description:	Based on interviews with the licensee, the City of Fredericks burg building official and fire marshal, it was determined the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures. Evidence: An email received from the administrator of the facility on July28, 2020, documented 3 residents who tested positive for COVID-19 were relocated to a facility that was not licensed for residential care. The move was completed without the approval of the City of Fredericksburg building official, fire marshal or the Division of Licensing Programs, (DOLP), The administrator verified the relocation via telephone interview, of the same date.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-70-A
Complaint related:	Yes
Description:	Based on interview with the licensee it was determined the licensee did not report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: The licensee verified they were aware on June 24, 2020 that a staff person had tested positive for COVID-19. This information was not reported to DOLP as required.
Plan of Correction:	Not available online. Contact Inspector for more information.