Alpha House I

Violation cited by VDSS, complaint inspection : 22VAC40-151-(6)-1010-Y

Based on interviews, and observations, the facility failed to protect infants, toddlers, and young children from dangers in their environment. 1)The Licensing Inspector (LI) was on-site at the facility on 4/9/2025, 5/6/2025, and 5/23/2025. 2) LI observed the bedrooms of resident one (R1), resident two (R2), resident three (R3), and resident four (R4) at each on-site visit. 3) On 4/9/2025, LI observed a bassinette in R1’s room filled with rolled blankets, wipes, diapers, infant clothing, empty baby bottles, and trash. 4) On 5/6/2025, LI observed the bedroom floors of R1 and R2 to have small hazardous objects: cords, sippy cups, drink bottles, and trash on the floors. LI observed R1’s bassinette to have rolled blankets, wipes, diapers and trash inside. 5) Collateral contact one (C1) was interviewed via Teams meeting on 5/1/2025 and via phone on 5/13/2025. 6) C1 reported during the interview on 5/1/2025, that broken glass in R3’s bedroom was observed during a visit on 4/16/2025. C1 stated they directed staff to clean the glass up as it was dangerous for R3’s toddler. 7) The findings were discussed during the preliminary findings review. S4 acknowledged the findings. 8) The findings were reviewed during the exit interview. S4 acknowledged the findings

Violation cited by VDSS, complaint inspection : 22VAC40-151-(2)-230-B

Based on a review of records and interviews, the facility failed to follow its own policies and procedures as outlined in agency’s Mother/Baby Program. 1) Page 135, section 4 of the agency’s Mother/Baby program policy states “Adolescent mothers are responsible for the daily care of their children while at Alpha House. This includes meal planning and preparation, feeding, bottle preparation and sterilization, bathing, diaper changes and disposal of soiled diapers, maintaining sanitary living environment, stimulating play/reading, and recreational activities with their child. When the adolescent mother is at school or an appointment that is not appropriate for baby to attend, the infant will be in the care and supervision of staff.” 2) During the interview, C1 stated observing an infant with a sagging soiled diaper during a visit to the facility on 4/21/2025. 3) An incident report for staff two (S2) documents an incident dated 4/21/2025 and states “S2 felt it was the resident’s responsibility to change the infant’s diaper. S2 acknowledged they did not change the infant’s diaper.” 4) The infant’s mother was at school during the time of the incident. 5) Collateral contact one (C1) was interviewed on 5/1/2025. 6) The findings were discussed during the preliminary findings review. S4 acknowledged the findings. 7) The findings were reviewed during the exit interview. S4 acknowledged the findings.

Violation cited by VDSS, complaint inspection : 22VAC40-151-(4a)-820-5

Based on a review of records and interviews, the facility failed to ensure that resident one (R1) was not subjected to actions that were humiliating, degrading, or abusive. 1) An incident report for staff two (S2) documents an incident date of 4/23/2025 and states “S2 comes into work and immediately confronts R1 in a hostile manner, asking R1 why she’s downstairs. When R1 replies, S2 tells R1 that she doesn’t want to see her face and go to her room, and she doesn’t need to lie on her and all she does is lie on everybody. When R1 replies to S2, S2 then jumps up and refers to R1 out of her name”. Per the incident report staff three (S3) was able to diffuse the situation. 2) A personnel action form for S2 dated 4/23/2025, documents that S2 was removed from shifts at Alpha House I due to hostile words with R1 and placed on shifts at Alpha House II. 3) During an interview with S3 on 5/23/2025, S3 described the interaction between S2 and R1 as a “verbal altercation”. 4) The findings were discussed during the preliminary findings review. S4 acknowledged the findings. 5) The findings were reviewed during the exit interview. S4 acknowledged the findings

Violation cited by VDSS, renewal inspection : 22VAC40-151-(4)-720-A-3

Based on a review of a resident's record (R1), the agency failed to meet the objectives of the initial 30-day service plan. 1) An objective outlined on the initial 30- day service plan contained in R1's record indicated R1 would receive individual and group psycho-educational training at least seven times per week to address independent living skills and psychosocial needs. R1 will participate in psycho-educational activities such as social skill development, healthy relationships, communication, stress management, and impulse control will also occur once weekly under the facilitation of Alpha House staff. Mental Health Services: Individual counseling will be weekly or as directed by the clinician or deemed necessary/appropriate. 2) A review of the daily progress notes contained in R1's record indicated R1 participated group activities on specific dates, including a group discussion about time with toddlers on 1/19/2025, a movie group on 1/24/2025, a group meeting on 1/26/2025, and daily life skills on 1/21/2025. 3) A review of the case management and daily progress notes contained in R1's record, did not contain documentation demonstrating that R1 participated in psycho-educational activities, such as social skill development, healthy relationships, communication, stress management, and impulse control on a consistent 7 day period as outlined in the initial 30-day service plan.

Violation cited by VDSS, renewal inspection : 22VAC40-151-(4)-640-E-2

- Based on record review, DC 1, the agency failed to add the following information on the face sheet. 1. DC 1 date of discharge was 1/19/2024. 2, A review of face sheet DC1 did not contain a reason for the discharge.

Violation cited by VDSS, renewal inspection : 22VAC40-151-(4)-640-E-3

- Based on record review, DC 1, the agency failed to add the following information on the face sheet. 1. DC 1 date of discharge was 1/19/2024. 2, A review of face sheet DC1 did not contain the names and addresses of persons to whom the resident was discharged.

Violation cited by VDSS, renewal inspection : 22VAC40-151-(2)-220-A-4

- Based on record review, the agency failed to include the minimum education requirements for the job description of team leader. 1. (SR-I) was hired 8/3/20. 2. Job description reviewed in record for (SR-1) was signed by staff on 5/20/23 and did not include minimum educational requirements for the position of team leader. 3. The finding were discussed during the exit interview.

Violation cited by VDSS, renewal inspection : 22VAC40-151-(4)-640-E-4

- Based on record review, DC 1, the agency failed to add the following information on the face sheet. 1. DC 1 date of discharge was 1/19/2024. 2, A review of face sheet DC1 did not contain the forwarding address of the resident.

Violation cited by VDSS, renewal inspection : 22VAC40-151-(4)-640-E-1

- Based on record review, DC 1, the agency failed to add the following information on the face sheet. 1. DC 1 date of discharge was 1/19/2024. 2, A review of face sheet DC1 did not contain the date of discharge.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(3)-540-C

Based on observation, interviews with residents, and interviews with staff, the facility failed to keep the building free of vermin. 1) This Licensing Specialist and an accompanying Licensing Specialist conducted interviews on 10/4/23 in regard to a self-reported incident, the residents disclosed other issues in regard to vermin: a. Current resident, CR1- i. She stated the following – “My mother killed a snake!” She stated her mother who visited her on 9/11/23, killed a black snake, which was in the facility. She stated that staff, S4, saw the snake after she heard CR2 scream from the bathroom while holding her child. CR1 stated her mother grabbed the snake, which was stuck on a sticky mouse trap in the bathroom and took it outside to kill it. ii. CR1 also stated the facility had been experiencing an issue with mice for at least 45 days or more. She stated the last time she saw a mouse was on 10/1/23 at midnight while making a bottle in the kitchen for her newborn baby. She also stated a mouse entered her room two weeks prior to this interview. CR1 stated in the beginning that she would see three to four mice per day in the house, particularly near the kitchen. She also stated that staff had seen them in the office. b. Current resident, CR2 – i. She stated the following – “I saw a snake in the bathroom.” She stated she was holding her child, a one-year-old male, who is walking and crawling throughout the facility. She also stated the following – “The snake was stuck on a ...

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4a)-830-B

Based on review of the facility’s policy for “Pharmacological or Mechanical Restraints” and interview with staff, the language used in this document permits the use of pharmacological restraints, which is prohibited by the standards. 1) A document titled, “ Chemical or Mechanical Restraints” was provided by staff, S4, during this inspection as an updated policy and procedure document on 3/29/23. The footer of this document states the following – “Revised 2023.” 2) This facility’s document uses “Chemical” in lieu of “Pharmacological.” 3) This version of the document supports the use of mechanical restraints and states the following- “The use of mechanical restraints is prohibited except as permitted by other applicable state regulations or as ordered by a court of competent jurisdiction.” 4) S4 was interviewed on 4/5/23 during the preliminary findings meeting about this document. S4 acknowledged this statement was noted on this document. 5) The Licensing Specialist advised S4 that pharmacological and mechanical restraints are prohibited. 6) On 4/6/23, S4 emailed the Licensing Specialist another version of this document that includes this topic. S4 addressed this document was reviewed with staff in November 2022 and the document presented on 3/29/23 was shared in error. However, this version of the document allows the use of pharmacological restraint, which states the following - “The use of chemical restraints are administered only with written direction and and (sic) ...

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(1)-50-F

Based on review of current resident, CR3’s record and interview with staff, the facility failed to comply with its own medication policy. 1) The “Alpha House Policy and Procedure for Medication” was reviewed as it pertains to resident refusal, which is considered a medication error. 2) The policy states the following as it pertains to medication errors – “Medication errors shall be documented immediately by the staff on duty during the medication error or by the staff member discovering the medication error. A medication error is defined as any medication that is not administered as prescribed in time, dosage, strength, route, or patient.” This document also states the following – “Resident refusal of prescribed medication is a medication error.” 3) Upon review of CR3’s Medication Error documents, three were not consistent with the policy. The “Date & Time of Error” on each form are the following – 2/17/23 – 8:00 AM, 1/23/23 - 6:30 AM, and 1/16/23 – 9:30 PM. It was noticed that at least three staff members did not complete a new form for each resident refusal. Instead, these staff only signed and dated at the bottom of a form that had been completed by another staff member. a) For example, the form dated for 2/17/23 was correctly completed by staff, S6. However, beneath S6’s signature is S3’s signature. S3 noted the following dates on this form by their signature – 2/25/23 and 2/26/23. S3 did not complete new forms for the above-mentioned dates. b) Second example, the form ...

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4)-750-E

Based on review of current resident’s, CR1’s, medication administration record and interview with staff, the facility failed to demonstrate medications were administered as prescribed. 1) The medication administration record (MAR) has a box for staff to initial and note the time for each day of the month that medication is given. 2) The MAR for March 2023 for medication, M1, shows empty boxes for the evening dose on the following dates: 3/5, 3/13, and 3/28. 3) The MAR for March 2023 for medication, M2, shows an empty box on the following date: 3/28. 4) In addition, the “Alpha House Policy and Procedure for Medication” states the following – “Alpha House shall maintain a medication administration record of all medicines received by each resident and shall include: 1. Date the medication was prescribed; Drug name; 3. Schedule for administration; 4. Strength of medication; 5. Route; 6. Identity of individual who administered the medication; 7. Date the medication was discontinued or changed.” 5) These MARs were discussed with staff, S4, on 3/29/23. S4 acknowledged the MARs are incomplete, which demonstrates the medications were not administered as prescribed.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(2)-120-B

Based on review of the facility’s policy and procedure for the written decision-making plan and interview with staff, the facility failed to comply with the intent of the plan. Due to a limited number of characters in this field, the findings for this violation are on a separate document. These findings are available for review by submitting a Virginia Freedom of Information Act Request.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4a)-840-A

Based on review of the facility’s policy document titled, “Behavior Interventions,” and interview with staff, the facility failed to include all of the required elements. Due to a limited number of characters in this field, the findings for this violation are on a separate document. These findings are available for review by submitting a Virginia Freedom of Information Act Request.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(2)-220-A

Based on review of the personnel record and interview with staff, the facility failed to write a job description for each position assigned to staff, S3 and S5. 1) Staff, S3, was interviewed on 3/29/23. When asked about their job title, S3 mentioned the following, Relief Counselor, Transporter, and Administrator in Training (AIT). 2) S3 was interviewed again on 4/5/23 in order to obtain clarification about the AIT duties. 3) S3 stated their duties include, but are not limited to being trained to do the following- operational tasks, writing service plans, and coordinating appointments. 4) S3’s “Relief Counselor” job description in S3’s personnel file does not contain the above-mentioned duties. 5) S4 was interviewed on 4/5/23 and shared that S3 and S5 are receiving this type of training. 6) Upon review of S5’s job description, the additional duties listed by S3 are also not in S5’s job description.

Violation cited by VDSS : 22VAC40-151-(2)-240-B-10

Based on review of the personnel record and interview with staff, the facility failed to maintain an up to date personnel record for staff, S1. 1) Staff, S1, holds the position of Residential Relief Counselor. 2) The personnel record for S1 does not contain a current job description for Residential Relief Counselor. 3) During the interview, staff, S3,, acknowledged job description was missing from the personnel record.

Violation cited by VDSS : 22VAC40-151-(3)-540-C

Based on observation, the facility failed to keep the building free from roaches. 1) Staff, S4, was present during the inspection of the interior of the facility on 10/12/22. 2) While in the facility’s kitchen, two dead roaches were noticed on the floor in the pantry, which contained a variety of food products. 3) During the preliminary findings meeting, S4 was interviewed about the kitchen pantry. S4 confirmed and shared with S3 that there were two dead roaches on the floor of the pantry. 4) S3 acknowledged the inspection findings.

Violation cited by VDSS : 22VAC40-151-(4)-740-E-1-b

Based upon review of the current resident’s, CR1’s, record and interview with staff, the physical examination did not include the vision exam. 1) The “vision exam” element is blank on CR1’s physical examination document. 2) During the interview, staff, S3, reviewed CR1’s physical examination document and acknowledged the findings.

Violation cited by VDSS : 22VAC40-151-(4)-740-E-1-c

Based upon review of the current resident’s, CR1’s, record and interview with staff, the physical examination did not include the hearing exam. 1) The “hearing exam” element is blank on CR1’s physical examination document. 2) During the interview, staff, S3, reviewed CR1’s physical examination document and acknowledged the findings.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(2)-240-B-10

Based on review of the personnel record and interview with staff, the facility failed to maintain an up to date personnel record for staff, S1. 1) The personnel record does not contain a current job description. 2) Staff, S4, searched the personnel record on behalf of staff, S3. This document could not be found. 3) S4 acknowledged there is no job description in S1’s personnel record.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(2)-250-C

Based on review of the personnel record and interview with staff, the facility failed to ensure that staff, S2, completed an additional 15 hours of annual training applicable to their job duties. 1) Upon review of the personnel record, S2 completed 12 of the additional 15 hours of annual training. 2) S3 acknowledged the additional 15 hours of annual training had not been completed.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4)-750-F

Based on review of the medication administration record (MAR) and interviews with staff, the MAR was not maintained as required for medicines, M1 and M2, received by the current resident, CR1. 1) For the MAR dated for November 2021, the following was missing as it pertains to medication, M1 – 750.F.3.–Schedule for administration, 750.F.4.–Strength, and 750.F.5.–Route. 2) For the MAR dated for December 2021, the following was missing as it pertains to medication, M1 – 750.F.4.– Strength and 750.F.5.– Route. 3) For the MAR dated for December 2021, the following was missing as it pertains to medication, M2 – 750.F.1.–Date the medication was prescribed and 750.F.4.–Strength.