VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Carriage Hill Retirement
1203 Roundtree Drive
Bedford, VA 24523
(540) 586-5982

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: March 25, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Technical Assistance:

To ensure that the facility had a thorough understanding of standards; the LI and the Administrator had a discussion regarding standard 440 D.

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 monitoring inspection was initiated on 03/25/2021 and concluded on 05/04/2021. A self-reported incident was received by the department regarding allegations in the areas of resident care and related services. 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 did not support the self-report of non-compliance with standards or law. Any violations not related to the self-report but identified during the course of the investigation can be found on the violation notice.

Violations:

Standard #:	22VAC40-73-450-F
Description:	Based on resident record review, the facility failed to ensure that individualized service plans (ISP) were reviewed at least once every 12 months. EVIDENCE: 1. The most current ISP for resident 1 contains identified needs for the resident with a begin date of 02/27/2020 and that the expected outcomes/goals of these identified needs would be reviewed by 02/26/2021; however, the ISP does not contain documentation that these identified needs had been reviewed by 02/26/2021.
Plan of Correction:	Care Plan Coordinator will take part in an in-person training course for Individualized Service Plans. Administrator and/or Director of Nursing will review training with Care Plan Coordinator and provide oversight of Individualized Service Plans.