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: May 6, 2024

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 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:

Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/06/2024 4:05PM until 6:00PM 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: 8 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 2 Number of staff records reviewed: 2 Number of interviews conducted with residents: 2 Number of interviews conducted with staff: 2 Observations by licensing inspector: medication administration, medication cart audit 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 Jennifer Stokes, Licensing Inspector at 540-589-5216 or by email at Jennifer.Stokes@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-100-C-2
Description:	Based on facility policy review and medication cart audit, the facility failed to implement its infection control program regarding blood glucose monitoring. EVIDENCE: 1. The facility?s infection control plan, revised 05/18/2022, indicates on page 14 of 16 that the only time multiuse fingerstick devices may be used is if the resident is totally independent in all aspects of blood glucose monitoring and no assistance is provided by staff and that in all other situations single use, auto-retractable disposable fingerstick devices must be used and that all glucometers in the facility should be labeled with resident names in addition to the name labeled on the outside of the kits (storage case) with the resident?s name. 2. During the medication cart audit, it was noted by the licensing inspector (LI) and staff person 2 that the glucometer for resident 3 and the glucometer storage case for resident 3 did not contain the name of resident 3 on the glucometer itself or the case that the glucometer was located in. In addition, there was a multiuse fingerstick device located within the glucometer case for resident 3. Interview with staff person 2 revealed that staff have to provide blood glucose checks for the resident as the resident is not able to do so himself and conduct the blood glucose checks with the multiuse fingerstick device.
Plan of Correction:	The Administrator and Director reviewed the standard. 22VAC40-73-100-C-2, the noted violation, and Second Chance's Medication Management Policy. The Administrator and Director reviewed the Medication Management Policies with RMAs and provided them with education on the proper storage and usage of the glucometer machine for residents. The glucometer storage case was labeled with the resident name on it, the multi-use finger stick device has been removed. The Administrator and Director will continue to monitor RMAs.
Standard #:	22VAC40-73-270-1
Description:	Based on staff record review and staff interview, the facility failed to ensure that direct care staff shall be trained in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents for assisted living facilities that accept, or have in care, residents who are or who may be aggressive. EVIDENCE: 1. The record for staff person 2, date of hire 09/01/2023, does not contain documentation that they had training in methods of dealing with residents who have a history of aggressive behavior or of dangerously agitated states prior to being involved in the care of such residents. 2. Interview with staff person 3 confirmed that this is accurate and that the facility does accept or have in care residents who are or who may be aggressive.
Plan of Correction:	The Administrator and Director reviewed standard 22VAC40-73-270-1. A, the noted violation at Second Chance, the Administrator and Director will review all records to make sure all aggressive behavior training for staff is completed upon hire in orientation and a refresher course will be conducted annually. The Administrator and Director will review and conduct an audit on all training with Human Resources monthly.
Standard #:	22VAC40-73-580-A
Description:	Based on staff interview, the facility failed to ensure when any portion of an assisted living facility is subject to inspection by the Virginia Department of Health, the facility shall be in compliance with those regulations, as evidenced by annual reports from the Virginia Department of Health. EVIDENCE: During on-site inspection, evidence of an annual inspection by the Virginia Department of Health was unable to be produced. As of 05/09/2024, the licensing inspector (LI) was still not provided evidence of an annual inspection. Interview with staff person 3 confirmed that this is accurate.
Plan of Correction:	The Administrator and Director reviewed standard 22VAC40-73-580-A, the noted violation at Second Chance for the Health Department. The Director contacted the Health Department to schedule the annual inspection in the future the Administrator and the Director would reach out to schedule 5 months ahead to get in date on the books for the inspections due to the Health Department being behind in scheduling. The administrator and Director will continue to monitor to make sure this is done promptly.
Standard #:	22VAC40-73-680-H
Description:	Based on resident record review and staff interview, the facility failed to ensure at the time the medication is administered, the facility shall document on a medication administration record (MAR) all medications administered to residents, including over-the-counter medications and dietary supplements. EVIDENCE: 1. The record for resident 1 contained a physician?s order, dated 04/19/2024, for Miralax oral powder 17g oral daily dissolve in water before taking. 2. The May 2024 medication administration record (MAR) for resident 1 did not contain documentation that the resident has been administered the aforementioned medication during May 2024. Staff person 2 also noted that the May 2024 MAR for the resident did not include this information; however, staff person 2 stated that the registered medication aides (RMAs) have been administering the aforementioned medication to the resident.
Plan of Correction:	The Administrator and Director reviewed the standard 22VAC40-73-680H, and the violation was noted for Second Chance, The Administrator and the Director reviewed the Second Chance Medication Management Plan, and all MARs were reviewed to make sure all resident orders match the MAR and follow the policy according to the guidelines. The Administrator and Director will train RMA annually and as needed to make sure there are no mistakes. All MARs will make the physician orders and staff will be trained properly. The Facility is implementing electronic MARs to make sure there are no mistakes. The Administrator, Director, and Manager would monitor for compliance.
Standard #:	22VAC40-73-950-E
Description:	Based on staff interview, the facility failed to ensure that a review of the facility?s emergency preparedness and response plan was completed semi-annually with staff and residents. EVIDENCE: 1. Interview with the licensing inspector (LI) and staff person 2 during on-site inspection on 05/06/2024 revealed that staff person 2 was not aware when the last semi-annual review of the facility?s emergency preparedness and response plan was completed with staff and residents. 2. No documentation was available for review on 05/06/2024 to show that a semi-annual review has been completed.
Plan of Correction:	The Administrator and Director reviewed standard 22VAC40-73-950E, the noted violation, and Second Chance?s Emergency Preparedness Plan. The Administrator and Director reviewed the facility emergency preparedness plan at the next QA meeting which is on 05/29/2024 for review. The Administrator and Director will make sure that the QA plan is reviewed every 6 months in the months of May and November, in-service will be conducted, and make sure that the individuals and the staff sign off on the forms to stay in compliance with emergency preparedness.
Standard #:	22VAC40-73-990-B
Description:	Based on staff interview, the facility failed to ensure the facility?s written plan for resident emergencies shall be reviewed by the facility at least every six months with all staff and documentation of the review shall be signed and dated by each staff person. EVIDENCE: 1. Interview with the licensing inspector (LI) and staff person 2 during on-site inspection on 05/06/2024 revealed that staff person 2 was not aware when the last six month review was conducted on the facility?s written plan for resident emergencies with all staff. 2. No documentation was available for review on 05/06/2024 to show that a six month review has been completed.
Plan of Correction:	The Administrator and Director reviewed the standard 22VAC40-73-990-B, the violation noted Second Chance, The Administrator and Director will review with the resident the importance of what to do in case of an emergency and drills will be done so that each resident will understand what to do in case of an emergency. The Administrator and Director will conduct an audit every 6 months to make sure there is documentation done so that we can remain in compliance.