VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Heritage Green Assisted Living Communities
201 & 202 Lillian Lane
Lynchburg, VA 24502
(434) 385-5102

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: May 15, 2023 and June 27, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 PERSONNEL 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/15/2023 10:00AM until 2:30PM and 06/22/2023 10:19AM until 12:00PM 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 03/28/2023 regarding allegations in the area of: resident care and related services. The evidence gathered during the investigation did not support the allegations of the self-reported incident 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 #:	22VAC40-73-70-A
Description:	Based on document review and staff interview, the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. EVIDENCE: 1. The licensing inspector (LI) for the facility received an e-mail from staff person 2 on 03/28/2023 at 5:08PM that resident 1 had expired on 03/25/2023 at 4:45PM due to choking that resulted in the resident?s death. The incident report indicated that the Heimlich Maneuver and CPR were performed by facility staff and EMTs; however, attempts were unsuccessful. 2. Interview with staff person 2 confirmed that the regional licensing office was not notified within 24 hours of the incident.
Plan of Correction:	How: All incidents will be reviewed during the morning Managers? Meetings and will complete all necessary reporting. In the event an incident occurs on the weekend, the Executive Director and/or Resident Care Director will review all pertinent information to determine the need for notifying the regional licensing office within 24 hours. Any major incident that negatively affects or threatens the life, health, safety, or welfare of any residents will be reported promptly. Should an incident occur on the weekend and need to be reported, the Executive Director and/or Resident Care Director will be responsible for completing the report or assigning a Designee to do so. Ongoing: The Executive Director or designee will audit and monitor all reportable incidents to ensure reporting is completed within 24 hours of the incident and follow-up written report is completed within 7 days. This will be reviewed during our quarterly QA meeting for compliance.
Standard #:	22VAC40-73-260-A
Description:	Based on staff record review and staff interview, the facility failed to ensure that a direct care staff member maintained current certification in first aid and that the certification is either in adult first aid or include adult first aid. EVIDENCE: 1. The record for staff person 1 contains documentation that staff 1 completed the requirements for adult first aid/CPR/AED on 07/20/2020 and the document indicates that the certification is valid for two years. 2. The record for staff person 1 also contains documentation that staff 1 completed the requirements for basic life support (BLS) on 10/13/2022 and the document indicates that the certification is valid for two years; however, the licensing inspector (LI) verified with Collateral 1 that BLS does not include first aid training.
Plan of Correction:	How: Staff member 1 attended the Red Cross CPR class on June 30, 2023 to recertify her First Aid certification. Ongoing: The Business Office Director will be responsible to ensure either they or their designee will continue to complete a sample of employee chart audits monthly to ensure all appropriate trainings have been completed in a timely manner. The Executive Director will be responsible to ensure either they or their designee will verify the appropriate CPR and First Aid classes have been scheduled as needed. The Executive Director and Business Office Director will use monthly audits to measure compliance and the results will be reviewed during our quarterly QA meeting.