VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Vitality Living West End Richmond
1800 Gaskins Road
Henrico, VA 23238
(804) 741-8880

Current Inspector: Kimberly Davis (804) 662-7578

Inspection Date: Sept. 21, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-73 ADMINISTRATION AND ADMINISTRATIVE SERVICES 22VAC40-73 RESIDENT CARE AND RELATED SERVICES

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 monitoring inspection was initiated on 9/22/2020 and concluded on 11/4/20 to follow-up on a self reported incident. The inspector reviewed one resident record, staff schedules, the resident's individualized service plan and the review of appropriateness for continued residence in the secure unit for the residen Information gathered during the inspection determined non-compliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. The facility has 10 calendar days from receipt of the inspection reports to complete a plan of correction, sign the inspection reports and return them to the licensing office. A copy of the inspection reports shall be retained to be posted at the facility. Results of the inspection are subject to public disclosure and will be posted on the VDSS website within 15 calendar, regardless of whether the plan of correction is completed .Just writing the word ?corrected? is not acceptable. The plan of correction shall include the following: (1) Step(s) the facility will take to correct the violations cited; (2) Measures that will be put in place to prevent reoccurrence of each violation; (3) Person(s) responsible for implementation and monitoring of preventive measures; and (4) Date by which each violation will be corrected.

Violations:

Standard #:	22VAC40-73-70-A
Description:	Based on a review of facility documentation regarding an elopement at he facility, the facility failed to report to the regional licensing office within 24 hours an incident that negatively affected or that threatened the life, health, safety, or welfare of a resident. Evidence: The Central Region licensing office received an incident report on 9/21/2020 via email reporting the elopement of a resident (#1) from the secure memory care environment that occurred on 9/21/2020. The report was not received within 24 hours of the incident occurrence. The report received documented that the resident was found 200 meters from the facility at a street light. The Review of Appropriateness of Continued Residence in Special Care Unit form dated 8/29/20 completed by facility staff #1 document "resident requires 24 hour secure unit due to inability to recognize danger to self or others".
Plan of Correction:	In service the care team on proper protocol of reporting of incidents. Ensure the reports are sent with in the time frame required. 9/21/20 In-service care team on proper protocol to report incidents. 9/21/20 Health and Wellness Director and Executive Director reviewed the process of timely report to department of social services.
Standard #:	22VAC40-73-460-D
Description:	Based on a review of a self reported incident, the facility failed to provide supervision of a resident schedule, care, and activities to prevent wandering from the premises. Evidence: The facility self reported that resident # 1 had wandered from the facility on 9/15/20. An incident report received via email from staff # 2 documented that the resident was found 200 meters from the facility at a street light. Resident # 1 resides in a secure memory care environment and requires 24 hour supervision. Supervision was not provided to prevent the resident from wandering from the facility.
Plan of Correction:	Update the ISP/UAI to include daily walking to reduce exit seeking behaviors. As residents needs change and services are varied to cause a change in the care needs of the resident the UAI and ISP will be updated to show that new intervention. 9/16/20 started daily walks to reduce the exit seeking behavior..9/16/20 ISP and UAI were updated