VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Powell Residential, LLC
4101 Falconway Lane
Richmond, VA 23237
(804) 319-6246

Current Inspector: Angela Rodgers-Reaves (804) 662-9774

Inspection Date: Nov. 19, 2019

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. 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced renewal inspection was conducted on 11/19/19 by 2 licensing inspectors from approximately 2:15 p.m. - 5:15 p.m. Previous violations were reviewed and corrected. There are currently 2 residents in care at the facility. During the inspection, a tour of the facility was conducted, review of 3 resident records and 2 staff records, review of facility documentation, required facility postings were reviewed, first aid kit and emergency food/water supplies were checked, activity was observed, observation of medication pass, review of medication administration records and physician orders, interview of staff and residents conducted. An exit meeting was held with the administrator. Violations were cited during this inspection. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice and return to the Inspector 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 via e-mail at T.Lesley@dss.virginia.gov if further assistance is needed.

Violations:

Standard #:	22VAC40-73-160-A
Description:	Based on review of staff records and facility documentation, the facility failed to ensure that the administrator attend at least 20 hours of training related to management or operation of a residential facility for adults or relevant to the population in care within 12 months from the starting date of employment, with at least two of the required 20 hours of training focus on infection control and prevention. Evidence: 1) Staff #2 (administrator - start date of employment: 6/28/18) record contained a documented 18 hours of training being completed during the first 12 months of employment. 2) Staff #2 record did not contain documentation of required 2 hour training on infection control and prevention included in the 18 hours of training completed, within the 12 month employment period.
Plan of Correction:	Class on infection control was scheduled for staff #2 on 11/20/19. Staff #2 now has 20 hours of training completed. Staff #2 completed infection control training on 11/20/19. Going forward, Administrator will keep track of meeting training requirements prior to when they are due.
Standard #:	22VAC40-73-210-F
Description:	Based on review of staff records and facility documentation, the facility failed to ensure that all staff receive at least two (2) hours of training annually on infection control and prevention. Evidence: 1) Staff #1 (date of hire: 7/7/18) record did not contain documentation of annual infection control training being completed during the annual training period. 2) Staff #2 (date of hire: 6/28/18) record did not contain documentation of annual infection control training being completed during the annual training period.
Plan of Correction:	Staff #1 and Staff #2 completed infection control training on 11/20/19. Going forward, Administrator will ensure that infection control training is completed for staff within the first quarter of the year.
Standard #:	22VAC40-73-250-D
Description:	Based on review of staff records, facility documentation and interview with staff, the facility failed to ensure that staff submit annual health information required by these standards regarding tuberculosis (TB) examination and risk assessment, documenting they are free of TB in communicable form. Evidence: 1) Staff #1 (date of hire: 9/15/18) record contained a TB risk assessment last dated 7/7/18. 2) Staff #2 (date of hire: 6/28/18) record contained a TB risk assessment last dated 4/17/18. 3) Staff #2 confirmed during interview that annual TB risk assessments for staff had not been completed.
Plan of Correction:	TB assessments for Staff #1 and Staff #2 were completed on 11/20/19. Going forward, Administrator will ensure that TB assessment are completed annually for staff.