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: Dec. 8, 2021

Complaint Related: No

Areas Reviewed:

22VAC40-73 GENERAL PROVISIONS 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

Comments:

A renewal inspection was initiated on 12/08/2021 and concluded on 01/12/2022. On 12/08/2021 the Administrator was contacted by telephone to initiate the inspection. The facility did not have COVID-19 protocols in place therefore the onsite inspection was terminated on this date. The Administrator reported that the current census was 2. On 01/12/2022 the renewal inspection resumed and the inspector reviewed facility menus, activities calendar, fire inspection, health inspection, physician's orders, medication administration records and the UAI and ISP for the two residents in care. The facility record for the Administrator was also reviewed by the inspector. A walk through of the facility was also conducted by the inspector; accompanied by the facility Administrator. An exit interview was conducted with the Administrator on 01/12/2022 where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined noncompliance with applicable standards or law, and violations were documented on the violation notice issued to the facility. If you have any questions I can be reached at (804) 840-0253 or angela.r.reaves@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-90
Description:	Based on the review of facility records and the interview with the facility Administrator, the facility failed to ensure that the facility maintained a written accounting of money received and disbursed by the licensee, facility administrator, or staff person that shows a current balance. The written accounting of the funds shall be made available to the resident at least quarterly and upon request, and a copy shall also be placed in the resident's record. Evidence: Resident #1-Documented date of admission 08/15/2018 Resident #2-Documented date of admission 09/19/2018 The facility Administrator did acknowledge that he received money on a monthly basis for the resident?s care needs but upon request did not submit for the inspector?s review documentation of written monthly accounting of money received and disbursed by the licensee, facility administrator, or staff person that shows a current balance for resident #s 1 and 2.
Plan of Correction:	FACILITY RESPONSE: "Going forward the facility will monitor monthly accounts for both residents per current regulations."
Standard #:	22VAC40-73-210-A
Description:	Based on the review of facility records and the interview conducted with the facility Administrator the facility failed to ensure that all direct care staff for a facility licensed only for residential living care attended at least 14 hours of training annually. Evidence: Staff #1-Documented date of hire: 06/28/2018 The facility Administrator reported on 01/12/2022 that he is the only staff person currently employed at the facility. Upon request the facility Administrator did not submit for the inspector?s review documentation that he had completed 14 hours of annual training.
Plan of Correction:	FACILITY RESPONSE: "Going forward, the facility will ensure that all staff obtain the required annual staff development hours of training."
Standard #:	22VAC40-73-280-D
Description:	Based on the interview conducted with the facility Administrator the facility failed to ensure that at least one direct care staff member was on duty at all times in each building when at least one resident is present. Evidence: Resident #1-Documented date of admission 08/15/2018 Resident #2-Documented date of admission 09/19/2018 While outside of the facility on 12/08/2021 the facility Administrator stated during the COVID screening telephone interview that he was not onsite at the facility. The facility Administrator further clarified during this telephone interview that he was the only staff person for the facility and that there were two residents currently onsite and no staff person. For approximately one hour the residents were left at the facility without staff supervision.
Plan of Correction:	FACILITY RESPONSE: "Going forward the facility will ensure all residents are supervised at all times."
Standard #:	22VAC40-73-320-B
Description:	Based on the review of facility records and interviews conducted with the facility Administrator the facility failed to ensure that a risk assessment for tuberculosis shall be completed annually on each resident as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it. Evidence: Resident #1-Documented date of admission 08/15/2018 Resident #2-Documented date of admission 09/19/2018 Facility records submitted for the inspector?s review while onsite on 01/12/2022 revealed that the most recent risk assessment for tuberculosis for resident #1 is dated 10/30/2019. The most recent risk assessment for tuberculosis for resident #2 is dated 12/21/2020.
Plan of Correction:	FACILITY RESPONSE: "The facility will ensure current T.B. screens are conducted on all residents as required."
Standard #:	22VAC40-73-440-H
Description:	Based on the review of facility records and the interview with the facility Administrator, the facility failed to ensure that annual reassessments and reassessments due to a significant change in the resident's condition, using the UAI, is utilized to determine whether a resident's needs can continue to be met by the facility and whether continued placement in the facility is in the best interest of the resident. Evidence: Resident #1-Documented date of admission 08/15/2018 Resident #2-Documented date of admission 09/19/2018 Facility records submitted for the inspector?s review while onsite on 01/12/2022 revealed that the most recent UAI for resident #1 is dated 06/19/2020 and the UAI for resident #2 is dated 06/09/2020.
Plan of Correction:	FACILITY RESPONSE: "The facility will set up a system to alert staff when UAI's are due."
Standard #:	22VAC40-73-450-F
Description:	Based on the review of facility records and the interview with the facility Administrator, the facility failed to ensure that Individualized service plans are reviewed and updated at least once every 12 months and as needed for a significant change of a resident?s condition. The review and update shall be performed by a staff person with the qualifications specified in subsection B of this section and in conjunction with the resident and, as appropriate, with the resident's family, legal representative, direct care staff, case manager, health care providers, qualified mental health professionals, or other persons. Evidence: Resident #1-Documented date of admission 08/15/2018 Resident #2-Documented date of admission 09/19/2018 Facility records submitted for the inspector?s review while onsite on 01/12/2022 revealed that the most recent ISP for resident #1 is dated 10/02/2020 and the ISP for resident #2 is dated 10/02/2020.
Plan of Correction:	FACILITY RESPONSE: "The facility will set up a system to alert staff when ISP's are due."
Standard #:	22VAC40-73-680-H
Description:	Based on the review of facility records and the interview with the facility Administrator, the facility failed to ensure that at the time the medication is administered, the facility documented on a medication administration record (MAR) all medications administered to residents, including over-the- counter medications and dietary supplements. Evidence: Resident #1-Documented date of admission 08/15/2018 Resident #2-Documented date of admission 09/19/2018 01/12/2022: It was revealed at approximately 1:17 p.m. while on site at the facility that facility staff #1 had signed the January 2022 Medication Administration Record (MARs) for resident #s 1 and 2 indicating that the resident?s 6p.m evening medications had already been administered. Observation of the resident?s packaged medications revealed that the medications had not actually been administered to the residents.
Plan of Correction:	FACILITY RESPONSE: " Registered Medication Aide will ensure that all medications are administered and MARS are documented per regulations."
Standard #:	22VAC40-73-870-E
Description:	Based on observation with the facility Administrator, the facility failed to ensure that all furnishings, fixtures, and equipment, including furniture, window coverings, sinks, toilets, bathtubs, and showers, are kept clean and in good repair and condition, except that furnishings and equipment owned by a resident shall be, at a minimum, in safe condition and not soiled in a manner that presents a health hazard. Evidence: A walkthrough of the facility on 01/12/2022 with the facility Administrator revealed the following: ? First floor bathroom: the shower curtain was observed to have stains; the cabinets of the basin was observed to have water damage; the wall mirror had stains around the base of the mirror and the toilet was observed to have brown stains at the base of the toilet. ? The night side table in bedroom #1 was observed to have dust build up and dust buildup was also observed on the alarm clock and the lamp. The interior furnishings of the facility is not being maintained.
Plan of Correction:	FACILITY RESPONSE: "Administrator will do a walk through every morning to ensure the interior of the facility is cleaned and being maintained."