VIRGINIA DEPARTMENT OF SOCIAL SERVICES

First Choice West
826 Sturgeon Road
Lawrenceville, VA 23868
(804) 731-9662

Current Inspector: Belinda Dyson (804) 662-9780

Inspection Date: April 27, 2020

Complaint Related: No

Areas Reviewed:

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 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Technical Assistance:

Standard 22 VAC40-73-450: Discussion on appropraite verbiage use and documenting clear sevice delivery approach when developing an Individualized Service Plan (ISP).

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 4/27/2020 and concluded on 5/12/2020. The administrator was contacted by telephone to initiate the inspection. The administrator reported that the current census was 3. The inspector emailed the administrator a list of items required to complete the inspection. The inspector reviewed 2 resident records, 2 staff records, facility documentation, medication administration records, physician orders, nursing notes and staff schedules 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. An exit meeting was held with the administrator. Please contact me via e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.

Violations:

Standard #:	22VAC40-73-450-C
Description:	Based on review of resident records, the facility failed to ensure that a description of all identified needs based upon the Uniform Assessment Instrument (UAI) be included in the Individualized Service Plan (ISP). Evidence: 1. Resident #1 (DOA 2/5/2018) current UAI dated 7/1/2019 has identified needs of assistance with bathing and transferring, however the updated ISP dated 3/6/2020 does not address these service needs. 2. Resident #1 (DOA 2/5/2018) current UAI dated 7/1/2019 has identified needs of assistance with shopping and housekeeping, however the updated ISP dated 3/6/2020 does not address these service needs.
Plan of Correction:	Resident #1 UAI updated. Addressed assistance needed with bathing and transferring. Resident #1 UAI updated. Addressed assistance needed with shopping and housekeeping.
Standard #:	22VAC40-73-940-A
Description:	Based on review of facility documenation and staff interview, the facility failed to ensure that an annual fire inspection be completed and report retained at the facility. Evidence: The last fire inspection completed that the facility has on file is dated 12/6/2018. As per interview with administrator, the last inspection conducted by the fire marshal was done in February 2020, but the written report has not been received.
Plan of Correction:	State Fire Marshal was contacted. Inspection report for February 2020 will be sent to the facility.