VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Virginia Home for Adults
2701 Border Road
Chesapeake, VA 23325
(757) 545-6219

Current Inspector: Lanesha Allen (757) 715-1499

Inspection Date: May 2, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 PERSONNEL 22VAC40-73 STAFFING AND SUPERVISION 22VAC40-73 ADMISSION, RETENTION AND DISCHARGE OF RESIDENTS 22VAC40-73 RESIDENT CARE AND RELATED SERVICES 22VAC40-73 RESIDENT ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE

Comments:

Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: An unannounced renewal inspection took place on 05/02/23 from 08:35 am to 3:55pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents present at the facility at the beginning of the inspection: 45 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 8 Number of staff records reviewed: 5 Number of interviews conducted with residents: 3 Number of interviews conducted with staff: 3 Observations by licensing inspector: Breakfast, an activity were observed. A medication pass observation was completed for six residents. The following was reviewed: resident and staff records, emergency preparedness drills, resident fire and resident emergency drills, medication carts, fire inspection report, health inspection report, and a staffing schedule. Water temperature was measured, and call bell system was monitored. Additional Comments/Discussion: None 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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on the record review the facility failed to report to the regional licensing office within 24 hours any major incident that has negatively affected or that threatens the life, health, safety, or welfare of any resident. Evidence: 1. The record for resident #2, contains a progress note dated 10/03/22 that documents ?resident was sent out 911, appeared to have a seizure.? A progress note dated 10/04/22 documents ?resident is being admitted for testing and monitoring, and on 11/10/22, resident returned from the hospital.? 2. Staff # 5 acknowledged an incident report was not submitted to the regional licensing office to report the hospital admission for resident #2.
Plan of Correction:	The Administrator will conduct training and send out a memo to all direct care staff and managers making them aware of the standard and expectation regarding major incidents involving a resident. The facility will advise all managers and staff to report any resident going out to the hospital to the Administrator and Manager on duty and the report will then go out to the regional licensing inspector within 24 hours followed by an incident report within 7 days.
Standard #:	22VAC40-73-450-C
Description:	Based on the record review the facility failed to ensure the ISP includes a description of identified needs based upon the UAI. Evidence: 1. Resident #2?s UAI dated 02/20/23 documents mechanical help needs for walking. The ISP dated 02/20/23 does not include documentation of the mechanical help needed for walking. 2. Resident #3?s UAI dated 10/17/22 documents mechanical help needed for walking. The ISP dated 10/17/22 does not include documentation of the mechanical help needed for walking. 4. Staff #5 acknowledged residents #2 and #3 ISP did not include the mechanical help needs for walking.
Plan of Correction:	The office manager and administrator will add the mechanical help to resident #2 and #3 ISP as it stated on the UAI they use a walker. When doing the ISP updates going forward the Administrator will do an additional final review with the RMA manager to reduce the risk of missing any needs that must be noted for the resident care. Date to be corrected.
Standard #:	22VAC40-73-620-B
Description:	Based on the record review the facility failed to ensure actions taken in response to the recommendations noted in subdivision 3 of this subsection (oversite of special diets) shall be documented in the resident?s record. Evidence: 1. Resident #3?s dietary note dated 01/14/23 documents ?the resident needs a specialized Gerd diet.? The resident?s physician order dated 01/04/23 documents a diagnosis of Gerd. The resident?s record does not contain documentation of the actions taken in response to the resident needs of a specialized Gerd diet. 2. Staff #5 acknowledged the resident?s record did not contain documentation of actions takes in response to the dietary note dated 01/14/23.
Plan of Correction:	The Resident #3 doctor will be notified and asked to review the dietician report again. Staff or manager will document a follow-up was done by the doctor and have the doctor document that the dietician recommendation was reviewed. If the doctor agrees with the recommendation of the dietician and writes a special diet order the order will be followed and all dietary and direct care staff will be advised of the need and diet plan. The Dr. note will be placed in the resident record. The diet plan will be made available for the resident and posted in the kitchen.
Standard #:	22VAC40-73-860-G
Description:	Based on observation the facility failed to ensure the hot water at taps available to residents shall be maintained within a range of 105?F to 120?F. Evidence: 1. During a tour of the facility with staff #6, the water temperature in a shared bathroom was measured 122.5 degrees F.
Plan of Correction:	Maintenance will monitor the water temperatures at least every 2 weeks to reduce the risk of the water temperature falling or rising out of range. Adjustments will be made, if necessary, at that time or as needed to ensure water is within 105-120 degrees. The administrator and office manager will note this routine water check on the office calendar and assist with a reminder to maintenance.
Standard #:	22VAC40-73-870-E
Description:	Based on observation the facility failed to ensure all showers shall be kept clean and in good repair and condition. Evidence: 1. During observation with Staff # 5 and staff #6 a shower located in the shared bathroom was observed to have a wet washcloth laying on the bottom/floor tile of the shower. The bottom/floor tile of the shower was observed to be cracking and separating from the wall of the shower. The grab bar located in the shower was observed to be rusted around the area connected to the wall.
Plan of Correction:	Maintenance will remove and repair any area in the shower floor that is worn or cracked. The tile in the shower will be replaced. Maintenance will repair this in a professional manner. Any rusted grab bar will be replaced. Maintenance and the administrator will ensure no shower needs repair as every 2 weeks we will conduct an inspection of all bathrooms. The wet washcloth was removed by housekeeping on the same day of visit. The administrator will remind our residents in our monthly meeting to please put their used towels and rags in the dirty laundry after taking a shower. Staff will observe showers during hourly rounds for tidiness.