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: Aug. 15, 2023

Complaint Related: No

Areas Reviewed:

22VAC40-73 RESIDENT CARE AND RELATED SERVICES

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 8-15-2023, 9:00 ? 9:25 a.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A self-reported incident was received by VDSS Division of Licensing on 6-29-2023 regarding allegations in the area of: Resident Care and Related Services An exit meeting will be conducted to review the inspection findings. The evidence gathered during the investigation supported the self-report of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the self-report but identified during the course of the investigation can also be found on the violation notice. 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 Alex Poulter, Licensing Inspector at 804-662-9971 or by email at alex.poulter@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-640-A
Description:	Based on record review and interview with staff, the facility failed to implement a written plan for medication management, including addressing procedures for administering medication and methods to ensure that staff who are responsible for administering medications meet the qualification requirements of 22VAC40-73-670. Evidence: The facility?s Medication Management policy dated 09-2019 documented, ?The Executive Director (or designee) will assure staff assisting or administering medications are trained per State requirements and have successfully passed required training prior to assisting or administering medications.? Staff #2 sent an incident report to the licensing office on 6-29-2023 via email that documented, ?Description of the Incident: During the course of a staff record audit, it was determined that [Staff #1] lacked a valid Medication Aide License while working as such?.Actions taken in response: [Staff #1]?s employment was terminated.? Staff #2 confirmed that Staff #1 did not meet the qualification requirements per 22VAC40-73-670 to administer medications, and that the facility?s medication management plan was not followed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-73-670-1
Description:	Based on record review and interview with staff, the facility failed to ensure that each staff person who administers medication be licensed by the Commonwealth of Virginia to administer medications; or be registered with the Virginia Board of Nursing as a medication aide. Evidence: Staff #1 was working in the facility in the role as medication aide from 3-30-2023 until 6-29-2023 when it was discovered by the `RVP of Operations? during an internal audit that Staff #1 was not licensed by the Commonwealth of Virginia to administer medications; nor was Staff #1 registered with the Virginia Board of Nursing as a medication aide. A sample of Medication Administration Records [MARs] provided by Staff #2 documented that Staff #1 was signing off as having administered medications throughout April 2023 to Residents #1 and #2. Staff #2 confirmed that Staff #1 was administering medications in the facility throughout the duration of employment with the facility to ?over 80 residents? and was not licensed by the Commonwealth of Virginia or registered with the Virginia Board of Nursing. The staff member who hired Staff #1 was no longer employed by the facility at time of the discovery of Staff #1?s lack of licensure.
Plan of Correction:	Not available online. Contact Inspector for more information.