VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Second Chance
524 Pisgah Church Road
Rice, VA 23966
(434) 392-9276

Current Inspector: Jennifer Stokes (540) 589-5216

Inspection Date: June 3, 2020

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 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS Article 1 Subjectivity 32.1 Reported by persons other than physicians 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2 Facilities and Programs.. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 COMPLAINT INVESTIGATION. 22VAC40-80 SANCTIONS.

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 6/3/2020 and concluded on 6/4/2020. The Administrator was contacted by telephone to initiate the inspection. The Administrator reported that the current census was 10. The inspector emailed the Administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, staff schedules, fire and health inspections, health care over sight, fire drills and dietitian reports submitted by the facility to ensure documentation was complete. 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.

Violations:

Standard #:	22VAC40-73-210-F
Description:	Based on a review of staff records, the facility failed to ensure all staff received 2 hours of annual training in infection control. EVIDENCE: 1. The training records for staff persons 1 and 2 do not have documentation that these individuals received at least 2 hours of training annually in infection control and prevention.
Plan of Correction:	The Administrator and Human Resource Coordinator reviewed the current OSHA/Infection Control/Prevention curriculum being utilized, along with current written acknowledgement forms and training records to ensure all meet current standard. The Administrator and Human Resource Coordinator will revise the current training records listing, training curriculum description, and staff written acknowledgement forms to ensure that all related trainings conducted are detailed and listed separately to indicate the precise number of hours trained for each required topic per standard. In addition, a record of all current COVID-19 related or other CDC, VDH, VADSS provided resources, trainings, or guidelines that have been completed since the beginning of the epidemic will be added to each employee?s training records.
Standard #:	22VAC40-73-450-C
Description:	Based on a review of resident records, the facility failed to ensure that all identified needs were addressed on individualized service plans (ISP's). EVIDENCE: 1. The fall risk rating dated 1/1/20 in the record for resident 2 has documentation of the resident being a risk for falls. The comprehensive ISP dated 2/20/20 does not identify this addressed need.
Plan of Correction:	The Administrator and ALF Coordinator reviewed the noted standard and all noted resident records. The Administrator revised the current ISP to address the current fall risk assessment specifically and with increased detail of the care and support required to prevent falls and injury. The Administrator and ALF Coordinator will review all resident ISP?s quarterly, unless otherwise necessary due to added need or change in support/service delivery, to ensure all areas of care needed are addressed and correct per standard.