VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tina's World of Love
1751 Church Street
Suite C
Norfolk, VA 23504
(757) 500-4306

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Dec. 29, 2021

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 GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS

Comments:

An unannounced monitoring inspection by two Licensing Inspector was conducted on 12/29/21 from 9:10 a.m. until 12:00 p.m. There were three participants present. Five participants are enrolled. One direct care staff, the assistant director, and the program director were present. Three participant records and three staff records were reviewed. No new staff had been hired. Participants were observed enjoying a morning snack upon entering the center. All participants actively participated in group discussion and game. The first aid kit was reviewed. Currently no medications are administered at the center.

Violations:

Standard #:	22VAC40-61-150-A-3
Description:	Based on record review and discussion, the center failed to ensure when adults with mental impairments participate at the center, at least four of the required annual staff training hours focus on topics related to participants' mental impairments. Evidence: 1. Staff #3 did not have four of the required hours in training related to topics related to participants? mental impairments. 2. Staff #1 was unable to provide documentation of completed training for Staff #3 as it relates to topics of the participants? mental impairments.
Plan of Correction:	Director will ensure all staff meet their required training hours annually.
Standard #:	22VAC40-61-220-G
Description:	Based on record review and discussion, the center failed to ensure the initial assessment be completed, signed, and dated by the assessor. Evidence: 1. Participant #3?s Assessment was not dated or signed by the assessor. The assessment also is not completed as it does not indicate whether or not Participant #3 requires assistance with using a wheelchair. 2. Staff #1 acknowledged Participant #3?s Assessment was not completed, dated or signed by the assessor.
Plan of Correction:	Director will ensure that all participant records are completed, signed and dated by the assessor going forward.
Standard #:	22VAC40-61-230-D
Description:	Based on record review and discussion, the facility failed to ensure the plan of care included descriptions of identified needs, dates identified, expected outcomes or goals, activities and services and dates of outcomes or goal achieved. Evidence: 1. Participant #1?s Assessment dated 8/23/2021 documented mechanical help and physical assistance with bathing, mechanical help and supervision with dressing, and bladder incontinence less than weekly. However, the plan of care (POC) dated 8/23/2021 does not provide the specific assistance required for bathing and dressing. It states the participant ?may need assistance? with bathing and dressing. Additionally, the POC states ?incontinent weekly or more? and does not specify whether the incontinence is with bowel or bladder. The POC also states that Participant #1 requires mechanical and physical assistance with transfers and walking; however the assessment states the participant requires supervision and mechanical help with transfers and walking. The POC also states the participant requires verbal cues and physical assistance with toileting; however, the assessment states Participant #1 requires mechanical help and supervision with toileting. 2. Participant #2?s Assessment dated 10/6/2021 documented the use of a cane for walking and transferring; however, the POC dated 10/6/2021 states ?the participant will be given physical assistance with walking and transferring as needed.? The assessment also documents a use of a shower chair with bathing; however, the POC does not provide the specific assistance required with bathing or the need to utilize a shower chair. The assessment also documents a preference for no dairy products and a diabetic diet which was not included on the POC. 3. Participant #3?s Assessment dated 8/18/21 documented a need for mechanical and physical assistance with bathing and dressing; however, the POC dated 8/18/21 does not provide the specific assistance required for bathing and dressing. It states the participant ?may need assistance? with bathing and dressing. The assessment also documents a need for human help and walker for climbing stairs; however, the POC does not address this need. 4. Staff #1 acknowledged the POCs for Participant #1, Participant #2 and Participant #3 did not accurately reflect the aforementioned identified needs.
Plan of Correction:	Director will ensure that assessment and plan of care needs and assistance match. Accurate documentation will be noted to reflect the needs and outcome of all participants. Participant needs of both assessment and plan of care will correspond with each other going forward.
Standard #:	22VAC40-61-460-I
Description:	Based on observation and discussion, the center failed to ensure disposable hand towels or air dryers are in each restroom at all times. Evidence: 1. On 12-29-2021, during a tour of the center with Staff #1, one of the restrooms did not have disposable hand towels or air dryer. 2. Staff #1 acknowledged the restroom did not have the aforementioned items.
Plan of Correction:	Center will ensure that all restrooms are adequately equipped with toilet paper and hand towels at all times.
Standard #:	22VAC40-61-460-J
Description:	Based on observation and discussion, the center failed to ensure if bathing facilities are provided there be handrails in stall showers and seating for use in the shower. Evidence: 1. On 12-29-2021, during a tour of the center with Staff #1, a stall shower was observed in one of the bathrooms. The shower did not have handrails or seating for use in the shower. 2. The Plan of Care for Participant #1 and Participant #3 indicated a need for mechanical assistance if bathing is needed. Participant #2?s Plan of Care indicated a need for a shower chair if bathing is needed. 3. Staff #1 acknowledged the shower did not have the aforementioned items.
Plan of Correction:	Center will purchase and install handrails and place a shower chair in bathroom shower. Shower chair will be purchased and placed in shower stall.