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: May 4, 2022

Complaint Related: No

Areas Reviewed:

Administration and Administrative Services Personnel Staffing and Supervision Admission, Retention and Discharge of Residents Resident Care and Related Services Buildings and Grounds Emergency Preparedness Mixed Population Safe, Secure Environment

Comments:

Date of Inspection: May 4 and 13, 2022 Type of Inspection: Monitoring Inspection If you have any questions or email changes, please do not hesitate to contact me at laura.lunceford@dss.virginia.gov. If you need a copy of any of the DSS Model forms or to review any inspection or regulation, you can find the information on the internet: www.dss.virginia.gov. Census 71 Number of records reviewed and interviews conducted- 4 resident records and 2 staff records, 5 interviews. All facility self-reported incidents since the last inspection were reviewed on this date. The Licensing Inspector observed the residents during activities and in the common areas. The Licensing Inspector reviewed the following documents during the inspection: pharmacy review, dietician report, fire drills, healthcare oversight, emergency drills, activity calendars and menus. The Licensing Inspector and the Administrator discussed the risk assessment ratings for the violations for this inspection. Please complete the ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and returned it to the office. You will need to specify how the deficient practice will be or has been corrected. Your plan of correction must contain: 1) steps to correct the noncompliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s).

Violations:

Standard #:	22VAC40-73-250-C
Description:	Based on staff record review and staff interview, it was determined that the facility failed to have documentation in the record as required. Evidence: Staff B had no documentation of a Sworn Disclosure within the record as required.
Plan of Correction:	All staff records will contain all data as required. Administrative staff will audit staff files to ensure accuracy.
Standard #:	22VAC40-73-250-D
Description:	Based on staff record review and staff interview, it was determined that the facility had no documentation of a subsequent tuberculosis evaluation as required. Evidence: Staff B had no current documentation of an annual tuberculosis evaluation as required.
Plan of Correction:	All staff will obtain an annual tuberculosis evaluation as required. Administrative staff will audit the staff records to ensure compliance.
Standard #:	22VAC40-73-450-F
Description:	Based on resident record review and staff interview, it was determined that the facility failed to update an Individualized Service Plan (ISP) as required to indicate a change in condition for a resident in care. Evidence: Resident A, B, C and D had no documentation in the record to reflect the wound care treatment plan.
Plan of Correction:	All ISPs will contain documentation to reflect any change in condition for residents in care. Nursing staff will audit resident records to ensure compliance.