VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Elms of Lynchburg
2249 Murrell Road
Lynchburg, VA 24501
(434) 846-3325

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: July 8, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL

Comments:

Type of inspection: Monitoring Date of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 07/08/2022 10:00AM until 1:00PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 05/23/2022 regarding allegations in the area of personnel. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the self-report of non-compliance with standard(s) or law. However, violation(s) not related to the self-report but identified during the course of the investigation can be found on the violation notice. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-130-A
Description:	Based on document review and staff interviews, the facility failed to ensure that all staff who are mandated reporters under 63.2-1606 of the Code of Virginia reported suspected abuse, neglect or exploitation of residents in accordance with that section. EVIDENCE: 1. Staff 1 emailed the regional licensing office (the licensing inspector (LI) of record for the facility) on 05/23/2022 and stated the following: ?I would like to report an alleged abuse involving (resident 1) and a staff which took place yesterday afternoon. APS and PACE has been notified. I will update you with any additional information i.e. assigned Family Service Specialist. I am in the process of conducting internal investigation.? 2. The LI called the local adult protective services agency (APS) that serves the facility on 06/23/2022 regarding which family service specialist the case had been assigned to and the LI was informed by staff at the local agency that an APS complaint had not been called in regarding the resident. 3. During on-site inspection on 07/08/2022, staff 2 revealed that APS had not been on-site to investigate the allegation of abuse against resident 1 and that there had been an allegation of abuse against resident 1 by staff 3 on 05/22/2022.
Plan of Correction:	- The facility will ensure that all staff who are mandated reporters under 63.2-1606 of the Code of Virginia will report suspected abuse, neglect or exploitation of residents in accordance with that section _APS was called and made aware of the allegation of abuse for resident 1. Staff 3 was suspended until APS completed their investigation. Once the investigation was completed and unfounded Staff 3 was allowed to return to work. Additional education was provided to Staff 3 on handling aggressive behaviors. Staff will be on re-educated regulations in regards to self-reports to DSS when occurrence of incident that negatively affects or threatens the life, health of safety or welfare of any resident. - The Designee will monitor and educate staff on following protocol for the self-report of incidents.