Poplar Springs Hospital RTC

Non-compliance, DBHDS unannounced inspection : 12VAC35-46-765. H. (1e) - Discharge summaries: 1. No later than 30 days after discharge, a comprehensive discharge summary shall be placed in the resident's ...

At the time of the inspection, the discharge summary for Individual #8 was not signed and placed in record until after the 30 day requirement.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-260. A. (11) Providers, through their directors, shall: 11. Cooperate with the human rights advocate and the LHRC to investigate and correct ...

• Per licensing report CAP Inspection #693, the provider's CAP response was due on 1/29/2026 Upon review, Employee #1 failed to adhere to the established deadline as instructed.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Upon review of CHRIS entry A:20250121, the provider's investigation included a review of video footage and a review of the provider's policy which revealed: • Employee #1 failed to follow the provider's supervision policy with timely rounding. • Individual #1 was found face down in the shower, purple, with a piece of their underwear tied around their neck. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Upon review of CHRIS entry A:20250120, the provider's investigation included a review of video footage and a review of the provider's policy which revealed: • Employee #1 failed to follow the provider's policy supervision policy with timely rounding. • Individual #1 was found in the shower, unresponsive, with a string around her neck. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. A. Each individual has a right to exercise his legal, civil, and human rights, including constitutional rights, statutory rights, and the ...

Upon review of CHRIS entry C:20250139, the provider's investigation included interviews with staff, Employee #1 and Individual #1 and a review of the provider's policy which revealed: • Employee #1 yelled at and used an incorrect tone with Individual #1. • Employee #1 failed to follow the provider's policy related to Therapeutic Boundaries. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of this regulation.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

Upon review of CHRIS entry A:20250071, the provider's investigation included an interview with Employee #1 and a review of the provider's policy which revealed: • Individual #1 began to bang her head on the floor in the milieu. • Employee #1 assisted Individual #1 and escorted her out of the milieu. • Employee #1 failed to report incident per the provider's policy. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-230. A. (3a) - Providers shall collect, maintain, and report the following information concerning abuse, neglect, and exploitation: 3. The ...

Upon review of the CHRIS entry A-20250072, Employee #1 failed to provide a written report of the results of the investigation via the department's web-based reporting application within 10 working days from the date in which the investigation began. The investigative findings were due on 8/1/25. As of 9/29/25, the investigative findings have not been entered.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-175. C. (8) Upon receipt of a complaint, providers shall: 8. Report the director's decision and action plan within 10 working days to the ...

"Upon receipt of a complaint, providers shall: Report the director's decision and action plan within 10 working days to the individual, authorized representative, if applicable, and human rights advocate." Upon review of the CHRIS entry C-20250082, Employee #1 failed to provide a written report of the results of the investigation within 10 working days from the date in which the investigation began. The investigative findings were due on 7/29/25. As of 9/29/25, investigative findings have not been entered.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entry A:20250069, the provider's investigation included a review of video footage, a review of employee schedule and a review of the provider's policies which revealed: Employee #1 was not scheduled to work on the day of the incident. Employee #1 took Individual #1 to the rear of the dayroom to bring Individual #1 a gift. Employee #1 took Individual #1 into an area where Individual #1 had been separated from peers. A male peer came behind Individual #1 and began choking her. Individual #1 was sent to the Emergency Department for further evaluation. Employee #1 failed to follow the provider's policies regarding therapeutic boundaries. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-260. B. (2d) - Providers shall require their employees to: 2. Protect individuals from any form of abuse, neglect, or exploitation by: 2d. ...

Upon review of the investigative summary into CHRIS entry A:20250051, OHR Advocate determined: Employee #2 failed to report suspected neglect to the director. Based on the information provided, there is a preponderance of evidence to support a violation of this regulation.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entry A:20250051, the provider's investigation included an interview with Individual #1, Employee #1 and other staff, and a review of the provider's policies which revealed: Employee #1 reported to work, was off balance and smelled of alcohol. Employee #1 began hugging Individual #1 and other patients excessively. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entry A:20250059, the provider's investigation included a review of camera footage and a review of the provider's policies which revealed: During visitation, Individual #1 entered the bathroom with her visitor and smoked a vape. Employee #1 failed to follow the provider's supervision policy. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-230. A. (2) Providers shall collect, maintain, and report the following information concerning abuse, neglect, and exploitation: 2. The director of ...

Upon review of CHRIS entry, A-20250080, the provider became aware of the incident on 8/19/25, and the date of entry into CHRIS is 9/10/25. As a result, the provider failed to report the allegation to the department via the department's web-based reporting application within 24 hours of receipt.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Examples of abuse include acts such as: 3. Use of language that demeans, threatens, intimidates, or humiliates the person; Upon review of CHRIS entry, C-20240120 the provider's investigation included interviews with Individual #1 and provider staff. Per the investigative finding, it was revealed that Employee #1 has been heard by other staff to speak in a louder tone that resembles yelling to Individual #1 and other patients. Based on the provider's investigation, there is a preponderance of evidence to support the provider's determination of violation.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entries A:20250014 & A:20250015, the provider's investigation included an interview with Individual #1 and Individual #2, a review of video footage and a review of the provider's policies which revealed: Employee #1 failed to follow the provider's supervision policy. Individual #1 and Individual #2 engaged in sexual activity. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. Upon review of CHRIS entries A:20240143 & A:20240144, the provider's investigation included an interview with Individual #1 and Individual #2, a review of the provider's policies and a review of video footage which revealed: • Employee #1 and Employee #2 failed to follow the provider's policy regarding supervision. • Individual #1 and Individual #2 engaged in sexual behavior while on the unit. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's substantiated finding of neglect.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Abuse" means any act or failure to act by an employee or other person responsible for the care of an individual in a facility or program operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, that was performed or was failed to be performed knowingly, recklessly, or intentionally, and that caused or might have caused physical or psychological harm, injury, or death to a person receiving care or treatment for mental illness, intellectual disability, or substance abuse. Based on the review of CHRIS entry, A-20240184, the provider's investigation included video review which revealed: • Employee #1 pushed Individual #1 instead of using a provider-approved restraint technique to prevent Individual #1 from engaging a peer-to-peer altercation • Employee #1 used excessive force to prevent a peer-to-peer from occurring. Per the provider's investigative finding, there is a preponderance of the evidence to support the provider's finding.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-110. C. (9a) - The provider's duties. 9. Providers shall comply with all applicable state and federal laws and regulations, certification and ...

Upon review of CHRIS entry A:20240183, the provider's investigation included an interview with Individual #1, a review of the provider's policies, and a review of camera footage which revealed: • Employee #1 implemented a technique that did not meet Handle with Care protocol. Based on the provider's investigative finding, there is a preponderance of evidence to support the provider's finding of a regulatory violation.

Non-compliance, DBHDS human rights inspection : 12VAC35-46-70. Each provider shall guarantee resident rights as outlined in § 37.2-400 of the Code of Virginia and in the Rules and Regulations to Assure the ...

Poplar Springs Hospital See OHR citations below.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. B. (2) In receiving all services, each individual has the right to: 2. Be protected from harm including abuse, neglect, and exploitation.

"Neglect" means failure by a person, program, or facility operated, licensed, or funded by the department, excluding those operated by the Department of Corrections, responsible for providing services to do so, including nourishment, treatment, care, goods, or services necessary to the health, safety, or welfare of an individual receiving care or treatment for mental illness, intellectual disability, or substance abuse. See § 37.2-100 of the Code of Virginia. Per the provider's investigative findings conducted through video review and staff admission, neglect was substantiated as Employee #1 did not follow policy and left their handbag in the patient area; which, allowed Individual #1 to gain access to a vape and utilize it.

Non-compliance, DBHDS human rights inspection : 12VAC35-115-50. D. (2) The provider's duties: 2. Providers shall develop, carry out, and regularly monitor policies and procedures that assure the protection ...

Per the provider's investigative findings, Employee #1 did not follow written policies as Employee #1 left their handbag in the patient area, allowing Individual #1 and Individual #2 to gain access to a vape pen.