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: March 15, 2022

Complaint Related: No

Areas Reviewed:

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 22VAC40-80 THE LICENSE.

Comments:

An unannounced monitoring inspection was completed from 10:30 a.m.-11:40 a.m. by Licensing staff. There are 4 residents in care at this time. A tour of the physical plant was completed. Physician's orders and medication administration records were observed. A sample size of 3 resident's records and 2 staff records were reviewed for compliance. No new personnel hired since last inspection. Violations cited are identified within this report. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector by (or within 10 days). You will need to specify how the deficient practice will be or has been corrected. Just writing the word "corrected" is not acceptable. Your plan of correction must contain: 1) steps to correct the non-compliance with the standard(s), 2) measures to prevent the noncompliance from occurring again; and 3) person(s) responsible for implementing each step and/or monitoring any preventive measure(s). Please contact me by e-mail at belinda.dyson@dss.virginia.gov if further assistance is needed. Thank you for your assistance during this inspection.

Violations:

Standard #:	22VAC40-73-250-D
Description:	Based on a review of staff records, 2 records did not have documentation of current annual tuberculosis screening. Evidence: Staff #1 and #2 records last date of TB screening is dated 2/9/2021.
Plan of Correction:	Administrator has scheduled the screenings for both staff members for 3/20/2022. Efforts were made in February but to no avail. The results will be placed in each staff persons chart. Designated staff member will make sure that all annual screenings are done timely according to the standards.
Standard #:	22VAC40-73-350-B
Description:	Based on a review of resident's records, one out of three records did not have documentation of sex offender screening prior to admission. Evidence: Resident's record #3 was admitted on 7/1/2021. No sex offender screening was available to review.
Plan of Correction:	Administrator will conduct the sex offender screening search online and will print and place results in the residents record. All preadmissions paperwork will be searched and verified on future admissions and will place in resident's file at admission.
Standard #:	22VAC40-73-390-A
Description:	Based on a review of resident's records, one out of three records did not have documentation of a resident's agreement at the time of admission. Evidence: Resident's record #3 was admitted on 7/1/2021. No resident's agreement was available to review.
Plan of Correction:	Designated staff member and Administrator found the resident's agreement. It was misplaced. Administrator and designated staff member will review all charts periodically to ensure the correct paperwork forms are filed in the correct sections and records.
Standard #:	22VAC40-73-450-F
Description:	Based on a review of resident's records, one out of three records reviewed individualized service plan was not current for the year review. Evidence: Resident's #2 ISP annual review was dated 2/13/2021.
Plan of Correction:	Administrator will ensure that the ISP will be reviewed and updated for resident #2. Administrator will ensure that all residents ISPs are reviewed and completed timely and placed in the resident's records.
Standard #:	22VAC40-73-490-A-2
Description:	Based on a review of the health care oversight it is not current for the quarter. Evidence: Date of entry for the health care oversight reviewed was 3/9/2021.
Plan of Correction:	Health Care Oversight is rescheduled for 4/2/2022. Administrator will ensure that the health care oversights are completed every six months as required. Administrator will schedule the oversights ahead of time to avoid them being overdue.
Standard #:	22VAC40-73-550-G
Description:	Based on a review of resident's records, two out of three records did not have documentation of annual review of resident rights and responsibilities. Evidence: Resident's record #1 and #2 last review dates were documented 2/11/2021.
Plan of Correction:	Administrator instructed Designated staff member to review the residents rights and responsibilities with all residents and place the documentation of date and signature in the residents records. Administrator and designated staff member will ensure that an annual review is completed and documented timely in all residents records.
Standard #:	22VAC40-73-560-I
Description:	Based on a review of resident's records, one out of three records did not have a picture or written description of the resident at the time of admission. Evidence: Resident's record #3 was admitted on 7/1/2021. No photo or written description was available to review.
Plan of Correction:	Administrator instructed Designated staff member to take the picture of resident on 3/15/2022 and placed in resident's record. Designated staff member will ensure that all residents records have a current picture and or written description.