VIRGINIA DEPARTMENT OF SOCIAL SERVICES

English Meadows Abingdon Campus
15089 Harmony Hills Lane
Abingdon, VA 24211
(276) 619-4572

Current Inspector: Rebecca Berry (276) 608-3514

Inspection Date: Aug. 3, 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 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

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: 08/03/2023, 9:40am to 2:49pm 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: 80 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 9 Number of staff records reviewed: 5 Number of interviews conducted with residents: 4 Number of interviews conducted with staff: 3 Observations by licensing inspector: Additional Comments/Discussion: 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 Becky Berry, Licensing Inspector at 276-608-3514 or by email at rebecca.berry@dss.virginia.gov.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to address all identified needs on the comprehensive Individualized Service Plan (ISP) for one of the nine resident files that were reviewed. EVIDENCE: 1. The Uniform Assessment Instrument (UAI) in the record for resident #5, dated 03/09/2023, identifies toileting, mechanical and human help, supervision, as an area in which the resident requires assistance. The ISP in the record for resident #5, dated 03/09/2023, states ?Resident to utilize grab bars as needed for steadiness when performing task of toileting? and describes the person who will provide services as ?Self.? The ISP does not address the need for supervision.
Plan of Correction:	All ISP certified staff inserviced by 8/11/2023 to ensure UAI and ISP match in level of assistance needed to perform task. Administrator/Designee to perform ISP audits of 3 residents once per month for 3 months to ensure the level of assistance on UAI and ISP correlate. ISP for resident identified was corrected on 8/3/2023. [SIC]
Standard #:	22VAC40-73-520-I
Description:	Based on observations made during the tour of the building, the facility failed to keep current the activities schedule. EVIDENCE: 1. When the LI toured the safe secure unit during the inspection on 08/03/2023, the activities calendar was observed to be dated for June 2023.
Plan of Correction:	Activity personnel and management staff educated by 8/11/2023 on ensuring calendars reflect correct date and are updated weekly. Administrator/Designee will check once weekly for 3 months to ensure compliance. Calendar was updated and August calendar posted by 8/11/2023. [SIC]