VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Clara's Adult Home West
2230 West Grace Street
Richmond, VA 23220
(804) 359-1468

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Aug. 4, 2021

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 ACCOMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDING AND GROUNDS 22VAC40-73 EMERGENCY PREPAREDNESS

Comments:

A renewal inspection was initiated on 08/04/2021 and concluded on 09/08/2021. The facility Administrator was contacted by telephone to initiate the inspection. The facility Administrator reported that the current census was thirteen (13). The inspector emailed the facility Administrator a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 2 resident records, 2 staff records, staff schedules, physician's orders, Medication Administration Records (MARs), and other facility documentation submitted by the facility to ensure documentation was complete. On 09/02/2021 upon arrival the facility Administrator was not on site. The inspection of the interior of the facility on this day was terminated due to the failure by the facility to comply with safety expectations. The noncompliance observed was discussed with facility staff, the facility Administrator upon his arrival to the facility and the inspector?s supervisor. The inspector did however conduct an observation of the exterior of the facility and was accompanied by the facility Administrator; technical assistance was offered. An exit interview was conducted with the facility Administrator on 09/02/2021, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. On 09/03/2021 the inspector conducted an inspection of the interior of the facility accompanied by the facility Administrator. Based on observation; technical assistance was offered. On 09/08/2021 the inspector conducted an onsite review of the facilitys? medication cart. Technical assistance offered and an exit interview was conducted with the facility Administrator. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return it to the licensing office within 10 calendar days. Please specify how the violation will be corrected. The plan must contain: 1) step(s) to correct the non-compliance with the standard(s), 2) measures to prevent the non-compliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventative measure(s). Thank you for your cooperation during this inspection. I can be reached at angela.r.reaves@dss.virginia.gov or (804) 840-0253.

Violations:

Standard #:	22VAC40-73-40-A
Description:	Based on the review of facility policy, interviews conducted with the facility staff and the Administrator and observation the licensee failed to ensure compliance with all regulations for licensed assisted living facilities and terms of the license issued by the department; with relevant federal, state, and local laws; with other relevant regulations; and with the facility's own policies and procedures. Evidence: Upon request to review the facility?s COVID-19 policy for screening visitors the facility Administrator submitted on 08/31/2021 via email a document titled ?Policy and Procedures for Covid-19 monitoring For the safety of Residents, Staff and Visitors ?Visitors Log?. The document in part also notes ?Staffs are required to ask the following information- Screening questionnaire? Upon arrival to the facility on 09/02/2021 to initiate the onsite renewal inspection and after the inspector conducted the DOLP COVID-19 screening questions with facility staff #1, facility staff #1 twice extended an invitation to the inspector to enter the facility without conducting the facility?s required COVID-19 Screening Questionnaire. The inspector reviewed the required COVID-19 protocol with facility staff #s 1and 2 and declined the invitation to enter the facility and terminated that portion of the inspection.
Plan of Correction:	FACILITY RESPONSE: "Corrective Actions: regarding 9/02/2021 renewal inspection. Administrator conducted in service DOLP COVID-19 protocols refresher with all staff in compliance to facility?s infection control policies on 9/3/2021."