VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Hope Haven
24532 Prince Edward Highway
Rice, VA 23966
(434) 392-9276

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 11, 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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS ARTICLE 1 ? SUBJECTIVITY 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

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: 05/11/2023 9:25AM until 2:00PM 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: 7 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: medication cart audit, emergency food/water, postings An exit meeting will be 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 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 #:	22VAC40-73-70-A
Description:	Based on staff interview, the facility failed to report to the regional license office within 24 hours any major incident that negatively affected or that threatened the life, health, safety, or welfare of any resident. EVIDENCE: During a phone call with staff 4 on 04/24/2023, staff 4 informed the licensing inspector (LI) that on 03/19/2023 resident 1 punched staff 5 ?in the face a few times? and when staff 5 was trying to ?get the resident off? of them, resident 1 accused staff 5 of abusing him. This incident that occurred on 03/19/2023 between resident 1 and staff 5 was not reported to the LI until 04/24/2023. Interview with staff 4 confirmed that this was accurate.
Plan of Correction:	The Administrator reviewed standard 22VAC40-73-70-A, the noted violation, and Hope Haven?s current policies and procedures related to incident reporting. The Administrator created and implemented a new incident reporting form per the noted standard?s requirements and reporting timelines, along with communication checklists/logs to ensure the facility maintains compliance with the noted standard for all future incidents. The incident report will include communication with all applicable entities as deemed required depending on the nature of the incident. The Administrator, or his designated assistant in the event of his absence, will be responsible for reporting all incidents within 24 hours per the requirements of the standard moving forward.
Standard #:	22VAC40-73-170-B
Description:	Based on staff interview, the facility failed to ensure that a manager, designated, and supervised by the administrator, to assist the administrator in overseeing the care and supervision of the residents and the day-to-day operation of the facility was employed at the facility. EVIDENCE: The facility, who has a shared administrator with another facility, did not have a qualified manager employed as of the day of inspection on 05/11/2023. Interview with staff 4 confirmed that the facility has not had a qualified manager as of November 2022.
Plan of Correction:	The Administrator reviewed standard 22VAC40-73-170 B and the noted violation. The Administrator submitted an Allowable Variance request on the day of the inspection for Staff 1 to be deemed as qualified based on the successful completion of Senior Living University?s Administrator Level-1 Certification Course and the attendance of DSS Phase II training. See allowable variance request for further details thereof. The Administrator will maintain communications with the licensing inspector during the AV request process and await further instructions and/or approval thereof. In addition, the Administrator and Human Resource Director will continue advertising and potential recruitment of a qualified facility manager to ensure compliance with the noted standard as quickly as possible. The Administrator has and will continue to increase the days and hours present in the facility to adequately oversee the care, supervision, and day-to-day operations at the facility until a qualified manager is in place.
Standard #:	22VAC40-73-640-A
Description:	Based on an audit of the medication cart, document review and staff interview, the facility failed to implement a portion of its medication management plan. EVIDENCE: 1. The facility?s medication management plan, revised 05/22/2022, indicates on pages 2 and 3 that in order for the facility to ensure an accurate count of all controlled substances that the facility will maintain a shift-change control medication log that will be utilized every shift and that at each shift change, or when a new registered medication aide (RMA) comes on shift and another RMA leaves a shift, all controlled substances will be counted and verified per the controlled medication log that is located in the medication administration record (MAR) records along with the shift-change control log for accuracy and that any discrepancies are to be reported to the administrator and the assisted living facility coordinator immediately. 2. At approximately 9:52AM during on-site inspection on 05/11/2023, it was noted by the licensing inspector (LI) and staff 1 that there were eight Gabapentin 600MG tablets in the medication cart for resident 5; however, resident 5?s controlled drug substance record located in the MAR binder for Gabapentin 600MG indicated that there were seven Gabapentin 600MG tablets remaining. 3. The LI noted during the audit of the medication cart that there was no shift-change control medication log being signed by on-coming and off-going medication staff. Interview with staff 4 confirmed that staff have not been utilizing and maintaining the shift-change control medication log that is referenced in the facility?s medication management plan.
Plan of Correction:	The Administrator reviewed standard 22VAC40-73-640-A, the noted violation, and Hope Haven?s Medication Management Plan. The Administrator reimplemented the shift change controlled medication audit log on the day of the inspection. In addition, the Administrator completed an audit of all controlled substances the day of the inspection and resolved the noted difference in Resident 5?s-controlled medication count. The Administrator contacted the applicable RMA who failed to log the administration of the morning dose on the day of the inspection as required. The applicable RMA reported to the facility the day of the inspection and correctly recorded/documented the morning dose as required. The Administrator contacted all RMAs and reviewed the noted standard, Hope Haven?s Medication Management Plan, and the requirements thereof, including and specifically the mandatory utilization of the shift change controlled medication audit log and required recording of all medication administrations on the resident MAR and Controlled Substance log. All RMAs received verbal supervision regarding the above noted standards and policies. The Administrator will conduct weekly audits of all medications, medication logs, and shift change controlled medication audit logs to ensure compliance and accuracy thereof. The Administrator and the Health Care Oversight Nurse will conduct monthly audits of all noted items for further oversight and compliance assurance.
Standard #:	22VAC40-73-650-A
Description:	Based on resident record review and staff interview, the facility failed to obtain a valid order from a physician or other prescriber prior to discontinuing a medication, dietary supplement, diet, medical procedure, or treatment. EVIDENCE: 1. Resident 1 was admitted to the facility on 01/23/2023. The report of resident physical examination for resident 1, signed and dated by the physician on 01/06/2023, indicates on page three for the resident to receive one Ensure Plus each afternoon. 2. Interview with staff 1 revealed that the resident has not been receiving the aforementioned dietary supplement and that she was unaware that there was an order for the resident to receive Ensure Plus. The record for resident 1 did not contain information that the resident has been receiving Ensure Plus each afternoon and the record did not contain a discontinue order for Ensure Plus.
Plan of Correction:	The Administrator reviewed standard 22VAC40-73-650-A, the noted violation, Hope Haven?s Medication Management Plan, Hope Haven?s policies and procedures, and Resident 1?s records. Following the review of the items noted above and communication with Resident 1?s previous placement/provider/hospital, it was determined that the noted physician order for Resident 1 was discontinued prior to his admission to Hope Haven ALF, however, it was not communicated on the hospital discharge summary records and Hope Haven?s admission physician orders as needed. The Administrator requested the D/C order from Resident 1?s previous provider and will update his records upon receipt. The Administrator also scheduled Resident 1 a medical appointment with his new primary care physician to review the potential need for the noted supplement based on the physical examination record on hand. The Administrator will proceed as directed if/when a new physician order is received. The Administrator will review all resident admission records to ensure 1) that medications and/or supplements noted on a resident?s physical examination report are listed on the resident?s admission physician orders, 2) that any discrepancies or conflicting orders are resolved prior to or at admission, including the receipt and retention of any applicable D/C orders as needed.
Standard #:	22VAC40-90-40-B
Description:	Based on staff record review, the facility failed to ensure criminal history record reports were obtained on or prior to the 30th day of employment for each employee. EVIDENCE: Staff 6 was hired at the facility on 01/09/2023; however, the Virginia Criminal History Record/Sex Offender and Crimes Against Minors Registry Search Form was not stamped as received by the Virginia State Police until 02/28/2023 indicating that the facility did not obtain the results a criminal history record report for staff 6 on or prior to the 30th day of the staff person?s employment.
Plan of Correction:	The Administrator and Human Resource Director reviewed the Regulations for Background Checks for Assisted Living Facilities and Adult Day Care Centers, the noted violation, and current system in place for ensuring compliance thereof. The Administrator reviewed the expectations of compliance with the Human Resource Director specific to the review and follow up processes required to ensure timely submission and receipt of all background checks within the allotted 30-day period and what is required to occur in the event of a delay in receiving a background check that is beyond the facilities control. completed an audit of all employee records to ensure compliance with the noted standard. The Administrator will 1) conduct monthly audits of all employee records and 2) conduct routine audits of all new employee records at the time of hire and within 30 days of employment to ensure the compliance of the noted standard moving forward.