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: 05/17/2022 from 10:20 am to 1:45 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: 17 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 5 Number of staff records reviewed: 4 Observations by licensing inspector: Medication pass, required postings, and an activity. 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 M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.
Based on record review, the facility failed to ensure direct care staff attend at least 12 hours of training annually.
Evidence:
1. During review of the training records, Staff #4 attended 4 hours of training in 2021.
Plan of Correction:
Staff #4 has been made aware that they was in violation for not fulfilling their annual training in 2021. They understand that they will be monitored going forward to ensure they get all of their training in 2022.
Standard #:
22VAC40-61-160-A-1
Description:
Based on record review, the center failed ensure each direct care staff member maintain current certification in first aid from the American Red Cross, American Heart Association, National Safety Council, American Safety and Health Institute, community college, hospital, volunteer rescue squad, or fire department.
Evidence:
1. Staff #5?s is direct care staff and was hired 2-28-2022; however, Staff #5 does not have a current certification in first aid.
Plan of Correction:
Staff #5 has been signed up for an American Red Cross First Aid/CPR/AED course on June 23, 2022. This was the first available dated for an in-person class.
Standard #:
22VAC40-61-180-E-2
Description:
Based on record review, the center failed to ensure all staff and volunteers have an annual tuberculosis risk assessment completed.
Evidence:
1. Staff #2 did not have a current annual evaluation for tuberculosis (TB). The last TB evaluation for Staff #2 is 12-23-2020.
Plan of Correction:
Staff #2 went to Velocity Urgent Care on the day of the inspection and now has an up-to-date TB evaluation in their file.
Standard #:
22VAC40-61-220-C
Description:
Based on record review, the center failed to ensure the assessment identify the person's abilities and needs to determine if and how the program can serve the participant.
Evidence:
1. The assessment for Participant #4 (dated 03-09-2022) does not identify if the participant needs assistance with bowel incontinence, wheeling, stairclimbing, or mobility.
Plan of Correction:
Participant #4's assessment has been corrected.
Standard #:
22VAC40-61-260-B
Description:
Based on record review, the center failed to obtain an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis (TB) in a communicable form no earlier than 30 days before admission.
Evidence:
1. The following participants had documentation of a tuberculosis risk assessment prior to admission: Participant #3 (dated 3/4/22) and Participant #5 (dated 10/7/21). However, the documentation does not indicate whether or not Participant #3 and Participant #5 are free from TB in a communicable form.
Plan of Correction:
Participant #3 and #4's TB test records have been corrected.
Standard #:
22VAC40-61-410-A
Description:
Based on observation, the center failed to ensure the interior and exterior of all buildings be maintained in good repair, kept clean and free of rubbish, and free from safety hazards.
Evidence:
1. During a tour of the center, there were several limbs and branches in the outdoor courtyard area. There were also several wooden benches noted with chips and dry rot which could be a safety hazard.
Plan of Correction:
The limbs and branches in the outdoor area have been removed. The property manager has been contacted about the chips and dry rot on the wooden benches. They are going to find someone to sand and repaint them in June.
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.
Find this content at:
http://www.dss.virginia.gov/facility/search/adc.cgi