VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Adult Day Services by Primeplus Senior Centers
7300 Newport Avenue
Suite 100
Norfolk, VA 23505
(757) 625-5857

Current Inspector: Donesia Peoples (757) 353-0430

Inspection Date: May 6, 2024

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/06/2024 from 9:35 am to 11:00 am. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 3 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 3 Number of staff records reviewed: 2 Number of interviews conducted with participants: 2 Number of interviews conducted with staff: 2 Additional Comments/Discussion: There were no medications administered or present in the center while onsite inspection. The following were reviewed: participant and staff records, fire drills, and the first aid kit. An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-160-A-1
Description:	Based on record review, the center failed ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department. Evidence: 1. Staff #1 works as direct care staff and does not have documentation of a current certification in first aid in their record.
Plan of Correction:	Staff #1 has been signed up for a CPR/First Aid Class offered by the City of Norfolk.
Standard #:	22VAC40-61-340-C
Description:	Based on interview, the center failed to ensure if a catering service or contract food service is used, the service shall be approved by the local health department. The center shall be responsible for monitoring continued compliance by obtaining a copy of the Virginia Department of Health approval. Evidence: 1. The center utilizes a contracted food service and was unable to provide a current copy of its Virginia Department of Health approval.
Plan of Correction:	TBD. Mercy Chefs is waiting for their annual inspection from the City of Portsmouth Health Department.
Standard #:	22VAC40-90-40-F
Description:	Based on record review and interview, the center failed to ensure if an individual takes a leave of absence for a period of six consecutive months that a new criminal history record report and sworn statement or affirmation are completed. A criminal history record report issued by the State Police shall not be accepted by the facility if the report is dated more than 90 days prior to the date of employment. Evidence: 1. Staff #3 confirmed Staff #1 was initially hired on 4/30/2018, left the center in 2020, and returned to the center in June 2023. 2. Staff #1?s record included a sworn statement completed 4/26/2018 and a criminal history record report completed 5/14/2018. 3. Staff #3 confirmed Staff #1 had a leave of absence for a period of six consecutive months and a new criminal history record report and sworn statement were not completed upon their return to work at the center.
Plan of Correction:	Staff #1 filled out a sworn statement 05/17/2024 and the background check form will be mailed to the State of Virginia Police Department on 05/20/2024.