VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Presbyterian Children's Home of Highland
425 Grayson Road
Wytheville, VA 24382
(276) 228-2861

Current Inspector: Jamie Morgan (276) 525-5656

Inspection Date: July 18, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-151 INTRODUCTION 22VAC40-151 ADMINISTRATION 22VAC40-151 RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCY PLANNING 22VAC40-80 THE LICENSE 22VAC40-80 THE LICENSING PROCESS

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: 7/18/2022 10:30 a.m. to 3:30 p.m. This inspection was conducted by two Licensing Specialists and observed by one Licensing Specialist. Number of residents in care at the beginning of the inspection: 10 A licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident?s records reviewed: 3 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 Additional Comments/Discussion: Discussion occurred regarding non-operable windows in residential cottages. The Licensing Inspector consulted the local Fire Chief and Building Official. The local Building Official inspected and reported the windows to be compliant with the 2018 Virginia Existing Building Code, Section 304.3 Replacement window emergency escape and rescue openings. An entrance conference was conducted with the Executive Director, Program Director, and Administrative Director. Additional documentation inspected included IVE Matrix, menus, health and fire inspections, and pool inspection. A preliminary findings review was completed on 7/18/2022. The Acknowledgement of Inspection form was signed and left at the facility. And exit interview was conducted by phone on 8/1/2022. 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 Dawn Caldwell, Licensing Inspector at 804-385-6864 or by email at dawn.caldwell@dss.virginia.gov Violation Notice Issued: Yes A copy of this document will be sent to the licensee/provider for signature.

Violations:

Standard #:	22VAC40-151-250-B-4
Description:	Violation: Based on record review, and interview, the facility failed to ensure Staff 3 (S3) received annual retraining in professional relationships and interaction among staff and residents. Findings: 1. The record for S3 documented training in maintaining appropriate professional relationships and interaction among staff and residents 4/13/2020. 2. The record did not contain documentation of subsequent retraining. 3. The findings was discussed during the exit interview. Staff 5 (S5) was interviewed. 4. S5 acknowledged the findings.
Plan of Correction:	The Program Director will review all documentation for training before filing to ensure that all staff members have been included in the training and documented on the training list. The Program Director is responsible for implementation of this plan.
Standard #:	22VAC40-151-800-A
Description:	Violation: Based on record reviews, the facility failed to develop and implement written behavior support plans within 30 days of admission for Residents 1 and 2 (R1 and R2). Findings: 1. The record for R1 contained a behavior support plan that did not identify positive behaviors or successful intervention strategies for problem behaviors. 2. The record for R2 contained a behavior support plan document that was not filled out. 3. The findings were discussed during the exit interview. Staff were provided the opportunity to review the records. 4. The Program Director reviewed the records and acknowledged the findings.
Plan of Correction:	The Program Director will review written behavior support plans prior to 30 days after admission to ensure that the plan includes all required elements and is placed in the file in a timely fashion. The Program Director is responsible for the implementation of this plan.