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: March 20, 2023

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 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 32.1 REPORTED BY PERSONS OTHER THAN PHYSICIANS 63.2 GENERAL PROVISIONS 63.2 PROTECTION OF ADULTS AND REPORTING 63.2 LICENSURE AND REGISTRATION PROCEDURES 63.2 FACILITIES AND PROGRAMS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS 22VAC40-80 COMPLAINT INVESTIGATION 22VAC40-80 SANCTIONS

Technical Assistance:

Discussion regarding ongoing issues related to acquiring current UAIs from the local CSB. Facility had documentation of continuous contacts. Direction was given to complete a private pay UAI to have things current until the CSB responded. Reminder that with an emergency placement a letter must be provided by APS or the physician making the placement. Licensing will try to assist the administrator in locating resources for additional staff training including ISP training. Discussion regarding resident capable of self-administering monthly injection and how monitoring would be documented.

Comments:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 3/20/23 The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 11. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. The facility has a follow-up fire inspection and date has been included on this final writing of the violation notice. The facility was clean and odor free. Number of resident records reviewed: 9 Number of staff records reviewed: 6 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 2 Observations by licensing inspector: The residents voiced no concerns with care despite the lack of documented training for the staff. The facility is licensed as residential only. Drills were documented as required. The facility had postings for activities and meals along with resident rights. Refer comments. Additional Comments/Discussion: Fire Inspection 3/29/23 Health Inspection 2/7/23 An exit meeting was conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee had 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. Should you have any questions, please contact Sharon DeBoever, Licensing Inspector at (540) 292-5930 or by email at sharon.deboever@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-210-A
Description:	Based on a review of staff records there was no documentation of 14 hours of annual training for staff A, C or D. There was no documentation of orientation training for staff B.
Plan of Correction:	Orientation will be completed with new staff person ? much of it was done just not documented. Administrator will begin working with CSB and other resources for the required training. The administrator will be responsible for correction and future compliance. Date noted reflects training process beginning.
Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records there was no documentation of annual TB tests for staff A, C or D.
Plan of Correction:	TB tests will be secured for all applicable staff. The administrator will be responsible for correction and future compliance.
Standard #:	22VAC40-73-320-A
Description:	Based on a review of a random sample of resident files, residents A and I did not have documentation of a physical and TB test. Although recently discharged, resident H admitted on 2/23/23 also did not have a physical on file. The administrator confirmed there was not one on file.
Plan of Correction:	Administrator will have physician update physical paperwork and TB tests for applicable residents. In the future the administrator or assistant will ensure that the TB and physical are included in the admission package and unless an emergency admission resident will not be allowed to move in without it. The administrator will be responsible for correction and future compliance.
Standard #:	22VAC40-73-390-A
Description:	Based on a review of a random sample of resident files, resident C did not have documentation of an agreement with the facility. The administrator confirmed there was not one on file.
Plan of Correction:	Administrator is having resident sign the agreement. If resident refuses, then will be discharged from facility. This will be coordinated with case management. The administrator will be responsible for correction and future compliance.
Standard #:	22VAC40-73-450-A
Description:	Based on a review of a random sample of resident files the following residents had no individualized service plan (ISP) on file: A admitted 3/3/23, G admitted 1/19/23 and J admitted 2/23/23. The ISP for resident C had no signatures from resident or other parties.
Plan of Correction:	Staff has a checklist as services are minimal since individuals are residential level of care. Admin and additional staff have registered for training April17th. The administrator will be responsible for correction and future compliance.
Standard #:	22VAC40-73-450-B
Description:	Based on a review of file for the person completing the individualized service plans it there was no documentation that the individual had successfully completed the department-approved ISP training. The administrator confirmed the lack of formally approved training.
Plan of Correction:	Administrator and an additional staff person are scheduled for training on April 17th.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of staff records there was no documentation of annual review of resident rights for staff A, C or D.
Plan of Correction:	Residents rights training will be updated for all staff and placed on an annual calendar. The administrator will be responsible for correction and future compliance.