VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Dominion Village at Poquoson
531 Wythe Creek Road
Poquoson, VA 23662
(757) 868-0335

Current Inspector: Alyshia E Walker (757) 670-0504

Inspection Date: Jan. 10, 2024

Complaint Related: Yes

Areas Reviewed:

22VAC40-73 STAFFING AND SUPERVISION 22VAC40-80 COMPLAINT INVESTIGATION

Comments:

Type of inspection: Complaint Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 1/10/2024 10:25 am- 3:19 pm The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. A complaint was received by VDSS Division of Licensing on 1/2/2024 regarding allegations in the area(s) of: Staffing Number of residents present at the facility at the beginning of the inspection: 36 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 0 Number of staff records reviewed: 17 Number of interviews conducted with residents: 0 Number of interviews conducted with staff: 1 The evidence gathered during the investigation supported the allegation(s) of non-compliance with standard(s) or law, and violation(s) were issued. Any violation(s) not related to the complaint(s) 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 Alyshia Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov

Violations:

Standard #:	22VAC40-73-1130-A
Complaint related:	Yes
Description:	Based on the employee timesheets reviewed, the facility failed to ensure that when 20 or fewer residents are present in the safe secure unit that at least two direct care staff members were awake and on duty at all times in the special care unit. Evidence: The staff schedule and employee timesheets provided by Staff #1 to licensing inspector for 1/1/2024 documented the facility?s safe, secure, unit had one staff member working from 7am- 3 pm shift.
Plan of Correction:	Steps to correct the noncompliance with the standard: HWD/ED to be notified of any schedule changes. If schedule coverage is not obtained, HWD/ED to cover Measures to prevent the noncompliance from occurring again: Staff training on callouts/schedule changes done on 1/24/24. Review of prn team members. Person(s) responsible for implementation of each step and/or monitoring preventative measures Charge nurse to notify HWD/ED timely of changes. HWD/ED to spot check schedule and spot checks of each shift to ensure schedule compliance