VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Helping Hands for Heroes
3315 High Street
Portsmouth, VA 23707
(757) 538-7900

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

Inspection Date: June 12, 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

Technical Assistance:

22VAC40-61-140 22VAC40-61-230

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: 06/12/2024 from 08:35 am to 11:05 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: 11 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 4 Number of staff records reviewed: 4 Additional Comments/Discussion: There were no medications administered in the center during the 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 Lanesha Allen, Licensing Inspector at (757) 715-1499 or by email at lanesha.allen@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-160-A-1
Description:	Based on record review, the center did not 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 #5 1/15/24 works as direct care staff and does not have documentation of a current certification in first aid in their record.
Plan of Correction:	Staff #5 first aid certification was done 5/23/2024, but due to technical issues was not hand at time of inspection.
Standard #:	22VAC40-61-180-E-1
Description:	Based on record review and interview, the center did not ensure each staff person obtain an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis in a communicable form no earlier than 30 days before or no later than seven days after employment or contact with participants. Evidence: 1. The record for Staff #3 hired 6/3/24 did not include documentation of an initial evaluation for tuberculosis (TB) consistent with the TB risk assessment as published by the Virginia Department of Health. 2. The initial evaluation for tuberculosis completed on 5/28/24 for Staff #4 hired 5/27/24 recommends a TB test due to a medical condition. There was no evidence of follow-up on this recommendation for further testing.
Plan of Correction:	Staff #3 TB test was completed. Future Note: No staff member will start employment without TB Screening. Staff #4 followed up with physician and was cleared with negative TB results.
Standard #:	22VAC40-61-230-A
Description:	Based on record review, the center did not ensure that prior to or on the date of admission, a preliminary plan of care based upon the assessment be developed for each participant. Evidence: 1. Participant #4 admitted to the center on 05/24/2024; however, the assessment in Participant #4?s record was dated 06/03/2024.
Plan of Correction:	Participant #4 did their intake on 5/4/24 however client did not start program 6/3/24. From this moment forward pan of care will be done according to specification.
Standard #:	22VAC40-61-230-F
Description:	Based on record review, the center did not ensure the participant, family member, or legal representative sign the plan of care. Evidence: 1. The plan of care for Participant #2 dated 10/17/23 is not dated nor signed by the participant, family member, or legal representative. 2. The plan of care for Participant #4 dated 6/3/24 is not dated nor signed by the participant, family member, or legal representative.
Plan of Correction:	Participant #2 care plan has been dated and signed by participant.
Standard #:	22VAC40-61-250-B
Description:	Based on record review, the center did not ensure the record contained a current photograph or narrative physical description of the participant, which shall be updated annually. Evidence: 1. The record for Participant #4 did not include a current photograph or narrative physical description of the participant.
Plan of Correction:	Participant #4 signed and dated plan of care. Participant also has current photograph and will be updated annually.
Standard #:	22VAC40-61-260-A
Description:	Based on record review, the center did not ensure within the 30 days preceding admission, a participant have a physical examination by a licensed physician. Evidence: 1. Participant #1 admitted to the center on 03/01/2024; however, the physical examination in Participant #1?s record was dated 06/05/2023.
Plan of Correction:	Participant #1 insurance will cover one physical a year. They are scheduled for physical on 6/24/24. From now on updated notes will be asked to be placed on physical stating no changes.
Standard #:	22VAC40-61-260-B
Description:	Based on record review, the center did not ensure the report of the required physical examination include the items listed in the standard. Evidence: 1. Participant #2?s physical examination (dated 11/08/2023) did not include a statement that specifies whether the individual is considered to be ambulatory or nonambulatory or a statement that specifies whether the individual is or is not capable of self-administering medication. 2. Participant #3?s physical examination (dated 09/26/2023) did not include a statement that specifies whether the individual is considered to be ambulatory or nonambulatory or a statement that specifies whether the individual is or is not capable of self-administering medication. 3. Participant #3?s physical examination (dated 12/05/2023) did not include a completed assessment for tuberculosis. 4. Participant #4?s TB Assessment (dated 05/29/2024) indicates immunosuppression and notes a previous positive TB with a recommendation to see their PCP for a chest x-ray. There was no evidence of follow-up on this recommendation for further testing.
Plan of Correction:	Participant #2 physical examination was updated to specify ambulatory or non-ambulatory. Participant #3 was discharged from program before making correction. Discharge 6/18/2024. TB screening was filed under hospital documentation. TB screening is on file. Photo also dated. Participant #4 followed up with physician and TB is cleared with negative results.
Standard #:	22VAC40-90-40-B
Description:	Based on record review, the center did not ensure to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #6 was hired on 04/27/2024; however, their background check was not completed during the onsite inspection on 06/12/2024.
Plan of Correction:	Staff #6 hired as Office Manager on 4/27/2024. For future, no one will start employment without background results.