\ VERMONT AGENCY OF HUMAN SERVICES DEPARTMENT OF DISABILITIES, AGING AND INDEPENDENT LIVING Division of Licensing and Protection HC 2 South, 280 State Drive Waterbury, VT 05671-2060 http://www.dail.vermont.gov Survey and Certification Voice/TTY (802) 241-0480 Survey and Certification Fax (802) 241-0343 Survey and Certification Reporting Line: (888) 700-5330 To Report Adult Abuse: (800) 564-1612 July 13, 2018 Angela Zizza, Manager Valley Terrace 2820 Christian Street White River Junction, VT 05001-9822 Dear Ms. Zizza: Enclosed is a copy of your acceptable plans of correction for the survey conducted on June 27, 2018. Please post this document in a prominent place in your facility. We may follow-up to verify that substantial compliance has been achieved and maintained. If we find that your facility has failed to achieve or maintain substantial compliance, remedies may be imposed. Sincerely, C----fmJa_14,14,4tA Pamela M. Cota, RN Licensing Chief Disability and Aging Services Licensing and Protection Blind and Visually Imparied Vocational Rehabilitation PRINTED: 07/03/2018 FORM APPROVED 'Division of Licensing and Protection STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: • (X2) MULTIPLE CONSTRUCTION STREET ADDRESS, CITY, STATE, ZIP CODE 2820 CHRISTIAN STREET VALLEY TERRACE WHITE RIVER JUNCTION, VT 05001 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG C 06/27/2018 B. WING 1004 NAME OF PROVIDER OR SUPPLIER (X3) DATE SURVEY COMPLETED A. BUILDING: ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 8100 R100 Initial Comments: An unannounced onsite relicensing survey,- complaint investigation, and a self-reported incident investigation was conducted by the Division of Licensing and Protection from 6/26 to 6/27/18. The following is a regulatory finding. . R181 V. RESIDENT CARE AND HOME SERVICES i, The background checks, Adult and (0 Child abuse registry for the 2 employees .in question were completed on 6/28/18. Both employee records came back with no findings on the Adult and Child abuse registries. An audit of all employee files took place on 6/29/18, by the Executive Director, and completed on 6/30/18. All employees presentlxworking in the facility have all the required background checks in a personnel file. All new employees will have background checks completed before an official offer of employment is 5.11 Staff Services 5.11,d The licensee shall not have on staff a person who has had a charge of abuse, neglect or exploitation substantiated against him or her, as defined in 33 V.S.A. Chapters 49 and 69, or one who has been convicted of an offense for actions related to bodily injury, theft or misuse of funds or property, or other crimes inimical to the public welfare, in any jurisdiction whether within f or outside of the State of Vermont. This provision shall apply to the manager of the home as well, regardless of whether the manager is the licensee or not. The licensee shall take all reasonable steps to comply with this requirement, including, but not limited to, obtaining and checking personal and work references and contacting the Division of Licensing and Protection in accordance with 33 V.S.A. §6911 to see if prospective employees are on the abuse registry or have a record of convictions. made. by_ Based on review of background checks of current' employees and staff interviews on 6/27/2018, the assisted living home failed to obtain the necessary background checks for 2 of the 5 employees reviewed. The specifics are detailed of Licensing and Protection TORY RECTORS OP OVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE EXer-u-t-■\re_ bil\e6-cir STA FOR 689'' 9.VIA 00C-clutfA-e4A KC WII The Business Manager will complete the background checks and report the results to the Executive Director. . An audit on background checks for new employees will be reported to the Quality Assurance committee on a quarterly basis. This REQUIREMENT is not met as evidenced Divis LA R181 8181 SS=D F2GH11 m p,tsii i (X6) 0i TE )1 110 L'8 If continuation sh et 1 of 2 PRINTED: 07/03/2018 FORM APPROVED ni‘iicinn of I irlaninn and Prot-Pt-firm STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (Xi) PROVIDERISUPPLIERICLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: C 06127/2018 B. WING 1004 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY TERRACE 2820 CHRISTIAN STREET WHITE RIVER JUNCTION, VT 05001 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG R181 Continued From page 1 ID PREFIX TAG (X3) DATE SURVEY COMPLETED PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE R181 below: Per review of 5 current employee personnel records, the home failed to assure that they had obtained the required background checks prior to hire. One employee had no background checks for either the Adult or Child registry, and the second employee was missing the Child registry check. The Executive Director confirms, during interview on 6/27/201.8, that the necessary background checks were not all completed for these 2 employees. Division of Licensing and Protection STATE FORM 6899 F2GH11 If continuation sheet 2 of 2