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: Nov. 9, 2023

Complaint Related: No

Areas Reviewed:

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: LI entered the facility at 1:30 pm on 11/9/2023 and exited at 2:15 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-report was received by VDSS Division of Licensing on 10/5/2023 regarding allegations in the area(s) of resident care and related services. Number of residents present at the facility at the beginning of the inspection: 17 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: 0 Number of interviews conducted with residents: 0 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 the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report 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 #:	22VAC40-73-450-E
Description:	Based upon a review of records conducted during a focused monitoring inspection on 11/9/2023, the facility failed to ensure that individualized services plans (ISPs) for one out of one resident were signed and dated by the resident or a legal representative. Evidence: 1. The ISP for Resident 1(R1) dated 10/22/2023 did not contain the signature of the resident or her legal representative.
Plan of Correction:	This has already been corrected,
Standard #:	22VAC40-73-460-D
Description:	Based upon a review of records and interview, the facility failed to provide supervision of resident?s schedules, care, and activities including attention to specialized needs such as wandering from the premises. Evidence: 1. According to an interview with Staff 1 that took place at approximately 1:45 pm on 11/9/2023, the facility had implemented 30-minute checks on R1 effective 11/1/2023, but staff working failed to complete the checks after 6 am on 11/4/2023. R1 left the premises sometime after 6 am and was reported missing by the facility to the local police department. 2. According to the log used to document the 30-minute checks on R1, no checks were done after 6 am on 11/4/2023. 3. According to written statement from Staff 2, who started shift at 6 am on 11/4/2023, ?I disarmed the alarm around 6:55 am, I was beginning my other morning duties and failed to do my rounds.? 4 According to written statement from Staff 3, ?I went to get (R1) for lunch when I saw she was missing. I hadn?t seen her or checked on her all day.?
Plan of Correction:	1. Staff 1 installed a timed checking system in each room near each residents? bed, staff must go in room with handheld device and touch plate on wall near bed, each round is done every 2 hours on every resident. The device then records the staff, the hour, and the route the staff took. 2. Staff 1 held a team meeting and went over the importance of the policies that are set in place and how to document them. 3. Staff 2 was suspended for 3 days with out pay starting on 10/6/2023 pending further investigation and on 10/10/2023 Staff 2 was terminated. 4. Staff 3 was also suspended for 3 days without pay starting on 10/5/2023 and on 10/9/2023 staff 3 was called in office and put on a 90-day probation due to the determining Resident 1 left before her shift started.