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: Sept. 11, 2023 and Oct. 2, 2023

Complaint Related: Yes

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

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: LI entered the facility at 10:55 am on 9/11/2023 and exited at 11:40 am. LI entered the facility at 11:30 am on 10/2/2023 and exited at 1:45 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 8/29/2023 regarding allegations in the area(s) of general provisions, administration and administrative services, personnel, staffing and supervision, admission, retention and discharge of residents, and resident care and related services. Number of residents present at the facility at the beginning of the inspection: 18 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 5 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 1 Observations by licensing inspector: Additional Comments/Discussion: An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported some, but not all of the allegations; area(s) of non-compliance with standard(s) or law were: administration and administrative services, personnel, and resident care and related services. A violation notice was issued; any violation(s) not related to the complaint, but identified during the course of the investigation can also 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 Jamie Eddy, Licensing Inspector at (703) 479-5247 or by email at jamie.eddy1@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-40-A
Complaint related:	No
Description:	Based upon review of records and interview, facility failed to comply with terms of the license issued by the department. Evidence: 1. The current approved capacity for the facility is 16. 2. On 10/2/2023 Licensing Inspector interviewed the administrator who reported that the facility currently had 18 residents in house.
Plan of Correction:	Placing residents in next level of care.
Standard #:	22VAC40-73-250-C
Complaint related:	No
Description:	Based upon a review of records, the facility failed to ensure that an original criminal record report and sworn disclosure statement are maintained in staff records for two of five staff. Evidence: 1. The staff record for Staff #2 did not contain a sworn disclosure statement or original criminal record report. 2. The staff record for Staff #4 did not contain the original criminal record report.
Plan of Correction:	Administrator is in the process of getting a state police account for all staff criminal background checks.
Standard #:	22VAC40-73-250-D
Complaint related:	No
Description:	Based upon record review, the facility failed to ensure that staff submitted annual results of a risk assessment documenting that the individuals were free of tuberculosis in a communicable form for four out of five staff. Evidence: 1. Staff records for Staff #2, #3, #4, and #5 did not contain documentation of a current tuberculosis assessment indicating the individuals were free of tuberculosis in a communicable form.
Plan of Correction:	Administrator will see that records are completed and kept up to date.
Standard #:	22VAC40-73-260-A
Complaint related:	No
Description:	Based upon record review, the facility failed to ensure that for every direct care staff member who did not have current certification in first aid received certification within 60 days of employment for three out of five staff. Evidence: 1. Staff records for Staff #2, #4 and #5 did not contain documentation of first aid certification within 60 days of employment.
Plan of Correction:	Administrator will see all staff has current first aid and kept up to date.
Standard #:	22VAC40-73-450-F
Complaint related:	No
Description:	Based upon a review of records, the facility failed to ensure that Individualized Service Plans (ISPs) were updated annually for two of five residents. Evidence: 1. The ISP for Resident #1 was last updated on 8/17/2022. 2. The ISP for Resident #5 was last updated on 8/18/2022.
Plan of Correction:	Administrator will see all residents? ISPs are current and up to date.