Presbyterian Children’s Home of the Highland

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4a)-800-A

Based on record review, the agency failed to develop and implement a written behavior support plan for Resident 4 (R4). 1. R4’s record did not contain a written behavior support plan. 2. S2 stated the plan had been developed. 3. S2 was provided an opportunity to locate the plan. 4. S2 acknowledged they were unable to locate the behavioral support plan during the inspectors’ visit. 5. S2 was provided additional time (another business day) to locate the requested documentation; however, the licensing inspectors did not receive additional documentation. 6. The finding was discussed at the preliminary findings review.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(5)-990-L

Based on review of documentation, the facility failed to maintain documentation, addressing required elements, for evacuations drills. 1. Documentation of the following evacuation drills did not include amount of time to evacuate the building: • 11/13/2022 9:30 a.m.- Webb Cottage • 10/17/2022 5:00 p.m.- Webb Cottage • 12/29/22 6:00 p.m.- Buchannan Cottage

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(4a)-860-D

Based on record reviews, the facility failed to contact the division superintendent of the resident’s home locality, for Child 2 (C2), a resident with a disability. 1. The record for C2 the child’s Individualized Educational Plan (IEP) documenting the child’s disability. 2. The record for C2 did not contain documentation of the facility’s contact with the division superintendent of the resident’s home locality. 3. The findings were discussed during the preliminary findings review. 4. Staff 5 (S5) acknowledged the findings. 5. The findings were reviewed during the exit interview and staff acknowledged the findings.

Violation cited by VDSS, renewal inspection : 22VAC40-151-(4a)-800-A

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). 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.

Violation cited by VDSS, renewal inspection : 22VAC40-151-(2)-250-B-4

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. 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.

Violation cited by VDSS, monitoring inspection : 22VAC40-151-(2)-250-B-1

Based on record review and interviews, the facility failed to ensure all employees completed an annual refresher emergency preparedness and response training. 1. The record for S1 did not contain documentation of annual refresher emergency preparedness and response training. 2. Staff 5 and 7 (S5 and S7) were interviewed. 3. S5 indicated the training did not occur and acknowledged the findings.

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

Violations: Based on the Licensing Inspector’s review of daily logs, interviews, and observation of video footage, interviews, and review of the daily log, the facility failed to ensure that a trained staff member managed the behavior of Resident 1 (R1). 1) During interview, Staff 1 and 2 (S2 and S3), reported P1 was not trained in the facility’s behavior management and restraint procedures. 2) The daily log for R1 on 1/10/2022, signed by Staff 3 (S3), documents following dinner R1 “..,had to be called down multiple times for not listening to staff instructions.” And “He later gets into an argument with staff member and then goes to the office to call his uncle then gets into an altercation that occurred with staff member.” 3) During interview, S3 reported a disagreement occurred between R1 and P1 regarding R1’s use of a skateboard in the cottage. P1 requested that the staff office be unlocked and the skateboard be placed in the office. S3 unlocked the office. S3 reported she left the office area to clean the kitchen area and use the restroom. 4) Video documented a sequence of interactions between P1 and R1 on 1/10/2022. The video did not contain audio. * *A separate document outlining a sequence of interactions observed in the video, referenced in the findings, was created and included with this violation notice and is available upon request**

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

Based on the Licensing Inspector’s review of the facility’s policies and procedures, personnel file documentation, daily logs, and interviews, the facility failed to comply with its own policies and procedures. 1) The Licensing Inspector requested and received the facility’s policies and procedures from Staff 2 (S2) on 2/2/2022. 2) The Licensing Inspector reviewed the Employee Handbook, which outlines the facility’s Policies and Procedures. The handbook specifies the following pertaining to behavior management techniques and prohibitions: • All direct care staff are trained in verbal intervention techniques; • Physical Restraint is only used by staff members who have received training in this area and when a child is in danger of hurting himself/herself or others; • All direct care staff members are trained … other staff members may report positive or negative behaviors to the direct staff members; • Only staff members certified in physical restraint may perform those techniques; • All direct care staff shall be trained by the Program Director or designated certified trainer within their first seven days of employment and annually thereafter; • All staff are responsible for helping with resident behavior; and • All staff shall be proactive, using positive management techniques as much as possible. 3) An Orientation Checklist in the record for Personnel 1 (P1) documented P1’s date of employment as 8/18/2021. 4) During interviews with Staff 1 and 2 (S1 and S2) on 2/11/2022, S1 ...

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

Violations: Based on the facility’s voice message report to the Licensing Inspector and the Licensing Inspector’s review of a Serious Incident Report, observation of video footage, and interviews, the facility failed to ensure that Resident 1 (R1) was not subjected to actions that were humiliating, degrading, or abusive. 1) Staff 2 (S2) left a voice message for the Licensing Inspector on 1/11/2022 and stated “…we filed a CPS complaint against one of our employees over a incident that happened last night, he had an altercation with in Webb cottage…the employee …putting his hands on the boy in a way he shouldn’t have.” 2) The record for R1 included a Serious Incident Report (SIR), signed by the Case Manager (CM). The SIR document documents an Incident date of 1/10/2022 at 8:00 p.m. in Webb Cottage and states “… [R1] became upset and began to argue with staff. [R1] began to use inappropriate language and gestures and wanted to speak with his family. Staff allowed him to call his family and continued to argue with [R1]. The verbal conflict resulted in the staff becoming physical with [R1] pushed and then placed [R1] in a chokehold.” The SIR notated that no physical restraint was used. 3) Video documented interactions between P1 and R1 on 1/10/2022. The video did not include audio. 4) Collateral Contacts 1, 2, and 3 (C1, C2, and C3) were interviewed by phone on 2/25/2022. 5) C2 reported R1 called him on 1/10/2022. C2 stated he placed the call on speaker phone so C3 could hear. C2 ...