22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-61 EMERGENCY PREPAREDNESS
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: Inspection Attempted: 06/21/2024 Time In: 11:16 AM; 06/26/2024 Time In: 10:13 AM Time Out: 2:00 PM The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Number of participants present at the facility at the beginning of the inspection: 140 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 8 Number of staff records reviewed: 4 Number of interviews conducted with participants: 0 Number of interviews conducted with staff: 2 Observations by licensing inspector: LI toured the physical plant of the facility. LI observed participants dining for lunch. LI observed participants sitting outside, interacting with peers in the lobby, utilizing the quiet room and massage chairs; and participating in activities, such as bingo and arts and crafts. Additional Comments/Discussion:
An exit meeting will be conducted to review the inspection findings.
The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. 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 Nina Wilson, Licensing Inspector at (703) 635-6074 or by email at nina.wilson@dss.virginia.gov.
Based on center record review, the center failed to ensure that the center provided an adequate number of qualified staff capable of carrying out the operation of the program and to develop a staffing plan that includes a staffing schedule. 1. The staff schedule was not provided upon request. 2. On 06/26/2024, LI interviewed Staff 5 (hire date, 03/01/2024), who stated, ?we do not have a staff schedule. Our staff works every day, for the whole day.? Staff 5 further stated, ?if we have a call out or someone takes vacation the nurse will work as direct care staff.?
Plan of Correction:
The center will develop a staffing plan that includes a staff schedule. The director will ensure that the schedule is stored along with all personnel file. The director will update the staffing schedule periodically to remove terminated staff and include new staff onto the schedule for licensing inspector?s review.
Standard #:
22VAC40-61-100-5
Description:
Based on center record review, the center failed to ensure that the all staff members shall be able to speak, read, understand, and write in English as necessary to carry out their job responsibilities. 1. The attendance list was written in Korean. LI was unable to read the list. 2. On 06/26/2024, LI interviewed Staff 5 (hire date, 03/01/2014), who stated, ?we don?t have a participant list written in English. The former LI would choose the participants based on the attendance list written in Korean.? 3. On 06/26/2024, LI interviewed Staff 5, who stated, ?you can review the daily sign in sheet? to determine staff to participant ratio. The form that the staff signed was written in Korean. The staff also completed the document in Korean. LI was unable to read the form.
Plan of Correction:
The center will create English versions of the attendance list and staff daily sign-in sheets. To ensure compliance, only the English versions will be used moving forward. The director will regularly monitor staff to confirm that the correct forms are being utilized.
Standard #:
22VAC40-61-110-A
Description:
Based on staff record review, the center failed to ensure that prior to working directly with participants, all staff shall receive training. 1. Staff 1?s (hire date, 12/19/2023) record did not contain documentation of initial training. 2. On 06/26/2024, LI interviewed Staff 5 (hire date, 03/01/2014). LI informed Staff 5 of two missing documents from the record. Staff 5 stated, ?Staff 1?s file should have everything. I will go look in a different place.? Staff 5 returned with one missing document but did not return with or provide documentation of Staff 1?s initial training.
Plan of Correction:
The center has located Staff 1?s initial training form, which was missing during the inspection. The director has now filed this record into the staff?s employee file. Moving forward, the Director will regularly review all staff records to ensure that all necessary documents are maintained.
Standard #:
22VAC40-61-130-A
Description:
Based on center record review, the center failed to ensure that the director, or a designated assistant director who meets the qualifications of the director, shall be responsible for the center?s program and day-to-day operations of the center and shall be present at least 51% of the center?s weekly hours of operation. 1. On 06/21/2024, LI arrived at the center at 11:16 AM and the director was not on-site. 2. On 06/26/2024, LI arrived at the center at 10:13 AM and the director was not on-site. LI interviewed Staff 5, who stated that the ?we do not have a staff schedule.? Staff 5 also stated, ?I work every day 8:30 AM until around 5 PM.? 3. On 06/26/2024, LI interviewed Staff 6, who stated, ?the director is here every day, from 8 AM to 5 PM.? 4. On 06/26/2024, LI interviewed Staff 5, who stated, ?I work every day 8:30 AM until around 5 PM.?
Plan of Correction:
The center will establish a staff schedule that ensures the director's presence for daily operations, guaranteeing that the director is on-site for at least 51% of the center's weekly operating hours. To ensure compliance, the staff schedule will be regularly revised to reflect any changes in the work hours
Standard #:
22VAC40-61-160-A-4
Description:
Based on staff record review, the center failed to ensure that there was at least one staff person on the premises at all times who has current certification in first aid, unless the center has an on-duty registered nurse or licensed practical nurse. 1. Staff 1 (hire date, 12/19/2023), Staff 2 (hire date, 02/28/2024), Staff 3 (hire date, 04/19/2023), and Staff 4(hire date, 07/25/2022), did not have first aid certifications on file. 2. On 06/26/2024, LI interviewed Staff 5, who stated, ?we have a nurse on duty, so I thought the staff did not need to have first aid.? Staff 5 was unable to provide a staff schedule to reflect that a nurse is on duty daily for the entirety of the center?s hours of operation. Staff 5 stated, ?we do not have a staff schedule.?
Plan of Correction:
Then center will have all direct care staff to obtain certifications in first aid. Upon completion, the director will file all certificates into each staff?s employee record for future review by the licensing inspector. The staff schedule will also clearly indicate that all RNs and direct care staff have first aid certifications. To ensure future compliance, director will require all new staff to undergo first aid training and obtain certifications. The director will regularly monitor the staff schedule and make any updates as needed.
Standard #:
22VAC40-61-260-B
Description:
Based on center observation, the center failed to ensure that the menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to participants. 1. On 06/26/2024, LI toured the center and did not observe a posted menu. 2. On 06/26/2024, LI interviewed Staff 5 who stated, ?the menu is posted next to the activity calendar.? LI requested Staff 5 to point out where it was located. Staff 5 acknowledged that menu was not posted.
Plan of Correction:
Upon receiving the physical examination form from the doctor?s office, the center will verify that all sections are fully completed. If any information is missing, the center will request that the doctor?s office provide the necessary details and resend the form. The director will periodically review all participant records to ensure that physical examinations are complete and accurate.
Standard #:
22VAC40-61-360-B
Description:
Based on facility observation, the facility failed to ensure that the menus for meals and snacks for the current week shall be dated and posted in an area conspicuous to participants. 1. On 06/26/2024, LI toured the facility and did not observe a posted menu. 2. On 06/26/2024, LI interviewed Staff 5 who stated, ?the menu is posted next to the activity calendar.? LI requested Staff 5 to point out where it was located. Staff 5 acknowledged that menu was not posted.
Plan of Correction:
The center will post the menus of the meals at a conspicuous area for all participants to see. The director will routinely inspect the posting board to ensure the menu is posted and updated on a weekly basis.
Standard #:
22VAC40-61-410-A
Description:
Based on center observations, the center failed to ensure that the interior and exterior of all buildings shall be maintained in good repair, kept clean and free of rubbish, and free from safety hazards. 1. On 06/26/2024, LI toured the center and observed an end table with chairs stacked on top, another set of stacked chairs beside it, a bucket, two mops, and an electric floor scrubber were located behind a partition, across from a seating area for participants in the front lobby. 2. On 06/26/2024, LI toured the center and observed an activity room with a vacuum cleaner unplugged with the cord laying on the floor and a fan plugged into a rectangular outlet surge protector with multiple tangled plugs attached as well. 3. On 06/26/2024, LI toured the center and observed a craft room with an open ladder standing against the wall. 4. On 06/26/2024, LI toured the center and observed an activity room with chairs stacked in front of a bookcase that stores games and other activities. 5. On 06/26/2024, LI toured the center and observed an entryway leading to stairs with rollators lined against the wall and plank wood with nails, a partition, wooden pole, and carpet pieces stacked on the stairs. 6. On 06/26/2024, LI interviewed Staff 5 (hire date, 03/01/2014), who stated, ?we share the building with two other businesses so many of the things are not ours.? Staff 5 further stated that ?staff are cleaning that is why some of the cleaning products are accessible.?
Plan of Correction:
The center will rectify all safety hazards identified during the inspection. To ensure future compliance, the director will inform all staff of potential risks associated with stacked chairs, cords left on the floor, and large items leaning against the wall. The director will conduct regular inspections of all rooms and activity areas to identify and address any further safety concerns, ensuring the well-being of all participants.
Standard #:
22VAC40-61-410-E
Description:
Based on center observation, the center failed to ensure that the cleaning products, pesticides, and all poisonous or harmful materials shall be stored separately from food and shall be kept in a locked place when not in use. 1. On 06/26/2024, LI toured the center and observed a storage closet with cleaning products, mops and buckets, vacuum cleaner, and other hazardous materials unlocked with the doors fully open. 2. On 06/26/2024, LI interviewed Staff 5 (hire date, 03/01/2014), who stated, ?the staff are cleaning. It?s not normally left open.?
Plan of Correction:
The center will ensure that the storage closet remains locked until all participants have left the premises. The Director will instruct the cleaning staff not to begin cleaning until all participants have departed.
Standard #:
22VAC40-61-520-C
Description:
Based on center record review, the center failed to ensure that the center developed and implemented an orientation and semi-annual review on the emergency preparedness and response plan for all staff, participants, and volunteers. 1. Upon request the center was unable to provide evidence of an annual and semi-annual review of the emergency preparedness and response plan.
Plan of Correction:
The center will create a form designed to record orientation and semi-annual review on the emergency preparedness and response plan for all staff, participants, and volunteers. The form will be maintained in the center?s policy book to ensure future compliance and review. During each review, director will monitor the plan and make any updates and revisions as necessary.
Standard #:
22VAC40-61-520-D
Description:
Based on center record review, the center failed to ensure that the center reviewed the emergency preparedness and response plan annually or more often as needed, document the review by signing and dating the plan, and make necessary revisions. 1. There was no documentation that the emergency preparedness and response plan was reviewed annually. 2. On 06/26/2024, LI interviewed Staff 5 (hire date, 03/01/2014), who stated that ?I didn?t know that I needed to document that I reviewed it.?
Plan of Correction:
The center will review the emergency preparedness and response plan at least annually. To ensure compliance, a reminder schedule will be established, requiring the plan to be reviewed, signed, and dated by the director annually or more frequently if necessary. The director will monitor and verify the documentation of each annual review to ensure it is completed as required.
Standard #:
22VAC40-61-540-E
Description:
Based on center record review, the center failed to ensure that a record of the required fire and emergency evacuation drills shall be kept in the center for two years. 1. The documentation for the fire drill was missing the identity of the person conducting the drill, the method used for notification of the drill, any special conditions simulated, the time of the drill, and weather conditions.
Plan of Correction:
The center will update the existing form to include the identity of the person conducting the drill, the method used for notification of the drill, any special conditions simulated, the time of the drill, and weather conditions. To ensure future compliance, the director will instruct staff to discard outdated forms and only use the updated version. The director will monitor compliance during each drill to ensure all required information is accurately recorded.
Standard #:
22VAC40-61-550-A
Description:
Based on center record review, the center failed to ensure that each building of the center and all vehicles being used to transport participants shall contain a first aid kit. 1. The first aid kit was missing scissors, tweezers, triangular bandage, flexible gauze, antibacterial cleansing solution, breathing barrier, an instructional manual; and the flashlight was inoperable. 2. On 06/26/2024, LI interviewed Staff 5 (hire date, 03/01/2014). LI informed Staff 5 that these components were missing and Staff 5 responded, ?okay.?
Plan of Correction:
The center will restock all missing items in the first aid kit. To ensure ongoing compliance, the director will establish an inventory log and regularly monitor the availability of all essential supplies. Any depleted or inoperative items will be promptly replenished or replaced by the director.
Standard #:
22VAC40-61-550-C
Description:
Based on center record review, the center failed to ensure that the first aid kit was checked at least annually, and contents shall be replaced before expiration dates and as necessary. 1. Upon request the center was unable to provide evidence of a review of the first aid kit. 2. The expiration date of the first aid kit was 09/30/2023.
Plan of Correction:
The center will establish an inventory log, which will be reviewed at least annually to ensure all items in the first aid kit are current. To maintain compliance, any depleted or expired items will be identified during the annual review and replenished promptly. After each use of the first aid kit, the director will monitor the log to determine if any supplies need to be replaced or refilled.
Standard #:
22VAC40-61-560-A
Description:
Based on center record review, the center failed to ensure that the center has procedures for handling mental health emergencies such as, but not limited to, catastrophic reaction or the need for a temporary detention order. 1. The participant emergency plan did not include mental health procedures. 2. On 06/26/2024, LI interviewed Staff 5 (hire date, 03/01/2014) who nodded his head when informed that the mental health procedures were missing from the plan. Staff 5 did not provide additional documentation or an explanation as to the reason.
Plan of Correction:
The center will develop a comprehensive plan and procedures for managing mental health emergencies, including catastrophic reactions or the need for a temporary detention order. To ensure ongoing compliance, this plan will be included in the center?s policy manual for reference and review. The director will regularly assess the plan to determine if any updates or revisions are needed.
Standard #:
22VAC40-90-60-B
Description:
Based on facility observation, the facility failed to ensure that pursuant of the Code of Virginia, any person, officer, or member of a governing board of any association or corporation that operates an assisted living facility, adult day care center, or child welfare agency shall be guilty of a Class 1 misdemeanor if he interferes with any representative of the commissioner in the discharge of his licensing duties. 1. LI was not provided any documents, such as Health Inspection, Fire Inspection, Liability Insurance, Participant List, Emergency Preparedness and Response Plan, and Staff List. 2. On 06/21/2024, LI arrived at the facility to complete a monitoring inspection. Staff 6 stated, ?we do not have inspections and the director is not here.? Staff 6 called the director while LI was present. Staff 6 passed the phone to LI. Staff 5 stated, ?I am 30 minutes away.? LI stated that she would start the inspection while the director was enroute. Staff 6 stated, ?the director is 30-minutes away. I am the manager, but I cannot give you anything that you?re looking for. You can wait or go; it is up to you. I cannot help.? 3. On 06/26/2024, LI arrived at the facility to complete a monitoring inspection. Staff 6 stated, ?the director is still not here. I will call.? Staff 6 returned and stated, ?the director is 30 minutes away. I cannot do the inspection, but you can wait for him.? Staff 6 provided a space for LI and walked away. Staff 6 returned approximately 20 minutes later and stated, ?he is 10 minutes away. You can do a tour, or you can wait until he gets here.?
Plan of Correction:
In case of the director's absence, the center will designate a back-up office staff member to assist the licensing inspector with her duties. To ensure ongoing compliance, the designated staff will be clearly identified in the staff schedule. The director will consolidate all licensing documents into a single file for easy access by the designated staff member, ensuring he/she can promptly provide the necessary information to the licensing inspector under any circumstances
Disclaimer:
This information is provided by the Virginia Department of Social Services, which neither endorses any facility nor guarantees that the information is complete. It should not be used as the sole source in evaluating and/or selecting a facility.
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