VIRGINIA DEPARTMENT OF SOCIAL SERVICES

The Lampstand- Straight Street Roanoke Valley, Inc.
333 Luck Ave SW*
*physical location not published
*location- AA Address
Roanoke, VA 24016
(540) 647-3222

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: May 30, 2023 , June 7, 2023 and June 14, 2023

Complaint Related: No

Areas Reviewed:

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: 5/30/2023 from 12:05 p.m. to 3:15 p.m. at the licensed location and 3:40 p.m. to 5:15 p.m. at the administrative office An additional visit was conducted on 6/7/2023 to the administrative office to review addition documentation for personnel records. The Acknowledgement of Inspection form was signed and left on 5/30/23 and 6/7/23. Number of residents in care at the beginning of the inspection: 3 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident?s records reviewed: 2 Number of staff records reviewed: 6 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1 A preliminary findings review was conducted on 5/30/23 and 6/7/23. An exit meeting was conducted by Teams Meet on 6/15/2023. 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

Violations:

Standard #:	22VAC40-151-190-B-1
Description:	Violation: Based on review of documentation, the facility failed to obtain, at the time of hire, tuberculosis screening assessments documenting absence of tuberculosis in communicable form for Personnel 1, 3, 5, and 6 (P1, P3, P5, and P6). Findings: 1) The facility staff listing documented the following hire dates for Personnel: a. P1- 2/14/2023 b. P3- 4/6/2023 c. P5- 4/3/2023 d. P6- 1/11/2023 2) Tuberculosis screening documentation for Personnel were dated: a. P1- 3/1/2023 b. P3- 4/11/2023 c. P5- 4/5/2023 d. P6- 1/12/2023 3) Findings were discussed during the preliminary findings review on 6/7/2023. The personnel identified above were trained at the facility's administrative office located 5 miles from the facility. The personnel were not onsite at the facility until screenings were completed. 4) Findings were reviewed during the exit interview on 6/14/2023 and Staff 1 and 2 (S1 and S2) acknowledged the findings.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-250-A-1
Description:	Violation: Based on review of personnel record documentation, the facility failed to document required training for Personnel 5 (P5), a staff member responsible for supervision of children. Findings: 1) The record for P5 did not document the basic orientation to the facility?s behavior intervention policies, procedures and techniques regarding less restrictive intervention. 2) The findings were discussed during the preliminary findings review with Staff 1 (S1) on 5/20/2023. 3) The findings were reviewed during the exit interview and Staff 2 (S2) indicated P5 did receive the required training and acknowledged it was later than 7 days from the begin date for P5.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-990-J
Description:	Violation: Based on documentation review and interview, the facility failed to complete all elements during monthly evacuation drills. Findings: 1) Monthly evacuation drill documentation dated 4/30/2023 and 5/11/2023 was reviewed by the Licensing Inspector. 2) Documentation for the 4/30/2023 and 5/11/2023 drills did not indicate practice alerting emergency authorities was completed during the drills. 3) Documentation for the 4/30/2023 drill did not document simulated use of emergency equipment was completed during the drill. 4) Findings were d discussed during the preliminary findings review on 5/30/2023. 5) Staff 1 (S1) reviewed the evacuation drill documentation and acknowledged the findings. 6) Findings were reviewed during the exit interview and S1 and S2 acknowledged the findings.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	63.2-1726-A
Description:	Violation: Based on review of documentation in personnel records and the facility?s staff list, the facility failed to obtain background checks prior to employees working. Findings: 1) The staff list provided by the facility documented the following hire dates for Personnel: a. Personnel 1 (P1), hired 2/14/2023 b. Personnel 4 (P4), hired 3/28/2023 c. Personnel 6 (P6), hired 1/11/2023 2) Central registry search results for the above personnel were dated: a. P1-2/18/2023 b. P4- 3/30/2023 c. P6- 1/12/2023 3) Criminal history search results for P4 were dated 4/10/2023 4) The findings were discussed during the preliminary findings review on 5/30/2023. Staff 1 (S1) reviewed the documents. 5) Discussion occurred regarding where staff are trained upon beginning work. The facility trains staff at the administrative office, approximately 5 miles from the facility. 6) S1 reports no staff are allowed to be at the facility until training and background checks are complete. 7) Findings were reviewed during the exit interview and Staff 1 and 2 (S1 and S2) acknowledged the findings.
Plan of Correction:	Not available online. Contact Inspector for more information.