VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Our Lady of the Valley
650 N. Jefferson St
Roanoke, VA 24016
(540) 345-5111

Current Inspector: Holly Copeland (540) 309-5982

Inspection Date: June 13, 2023

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint # 57420 Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 06/13/2023 from 01:30 PM until 04:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 05/05/2023 regarding allegations in the area(s) of: Multiple resident care concerns. Number of residents present at the facility at the beginning of the inspection: 21 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 1 Number of staff records reviewed: N/A Number of interviews conducted with residents: N/A Number of interviews conducted with staff: 2 Observations by licensing inspector: N/A Additional Comments/Discussion: N/A An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation did not support the allegation(s) of non-compliance with standard(s) or law. However, violation(s) not related to the complaint(s) 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 Holly Copeland, Licensing Inspector at 540-309-5982 or by email at holly.copeland@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-450-A
Complaint related:	No
Description:	Based on record review and staff interview, the facility failed to ensure that a preliminary plan of care to address a resident?s needs was completed on or within seven days prior to a resident?s admission. EVIDENCE: 1. The record for resident 1 indicated a date of admission of 03/08/2023 and the record also indicated that the resident was hospitalized on 03/12/2023 but did not return to the facility after that time. 2. On the date of inspection on 06/13/2023, the record for resident 1 did not contain a preliminary plan of care despite resident 1 living at the facility from 03/08 until 03/12. 3. An indication by staff 1 on 07/05/2023 revealed that the facility did not complete a preliminary plan of care for resident 1 on or within seven days prior to admission.
Plan of Correction:	1. Resident 1 did not have a preliminary care plan completed. 2. An audit was completed to identify residents who had a preliminary plan of care, on or within seven days prior to the day of admissions. 3. DON/designees were reeducated that new admissions must have a preliminary plan of care in place upon admission or within seven days prior to the day of admission. Effective July 1, 2023, all new admission will have a preliminary care plan in place, on the day of or prior to admission. The preliminary care plan will be submitted to the Assistant Administrator on the day of admission for 3 months, to ensure compliance was achieved. 4. Executive Director/designee will audit 50% of all new admissions records for completion of the preliminary care plan and report compliance to QA.