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F0607
E

Failure to Screen Volunteers per Abuse Prevention Policy

Charlottesville, Virginia Survey Completed on 07-17-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility staff failed to follow established abuse prevention policies regarding the screening of volunteers. Specifically, eight out of nine volunteer records reviewed showed that no criminal background check had been performed, and seven out of nine volunteers did not have a completed self-questionnaire about past or pending criminal charges. The activity director confirmed that volunteers, including a pastor, a former resident, and several church members, assisted with activities such as games and music. The activity director stated that all volunteers were supposed to complete an application and a self-questionnaire, which would then be reviewed by the administrator and human resources (HR) before a criminal background check was conducted. However, review of facility records and staff interviews revealed that these steps were not followed for most volunteers. The HR manager, who had been in her position since April 2025, reported that no new volunteer screenings had been requested or performed during her tenure, and a search of her portal confirmed that eight current volunteers had no criminal background check on file. The administrator acknowledged that background checks were required prior to volunteer service and that the activity director was responsible for obtaining the necessary documentation, while HR was responsible for conducting the background checks. The facility's abuse prevention policy clearly outlined these pre-screening requirements, but they were not adhered to for the majority of volunteers reviewed.

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