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 ACCOMMODATIONS AND RELATED PROVISIONS 22VAC40-73 BUILDINGS AND GROUND 22VAC40-73 EMERGENCY PREPAREDNESS 22VAC40-73 ADDITIONAL REQUIREMENTS FOR FACILITIES THAT CARE FOR ADULTS WITH SERIOUS COGNITIVE IMPAIRMENTS 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT 22VAC40-80 THE LICENSE
Comments:
Type of inspection: Renewal An unannounced renewal inspection took place on 08/06/24 at 9:11 am to 12:02 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection.
Number of residents present at the facility at the beginning of the inspection: 9 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident records reviewed: 4 Number of staff records reviewed: 3 Number of interviews conducted with residents: 1 Number of interviews conducted with staff: 1
Observations by licensing inspector: A tour of the center was completed to include outside and inside of the grounds. The facility?s fire drill logs and first aid kit were reviewed.
Additional Comments/Discussion: None
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 Donesia Peoples, Licensing Inspector at 757-353-0430 or by email at donesia.peoples@dss.virginia.gov
Based on the record review and staff interview the center failed to ensure each direct care staff member who does not have current certification in first aid as specified in subdivision 1 of this subsection shall receive certification in first aid within 60 days of employment.
Evidence: 1. The record for staff #2, hire date 10/30/23, did not contain a current certification in first aid. 2. Staff #4 confirmed the record for staff #2 did not contain a current certification in first aid.
Plan of Correction:
Staff #2 has been enrolled in a CPR/First Aid course offered by the City of Norfolk Parks and Recreation Department.
Standard #:
22VAC40-61-250-B
Description:
Based on the record review and staff interview the center failed to ensure the participant record shall include a current photograph or narrative physical description of the participant, which shall be updated annually.
Evidence: 1. The records for participants #2, #3, and #4 did not include a photo or narrative description for the participants. 2. A photo or narrative description for residents #2, #3, and #4 was requested and staff #4 was not able to provide a photo or narrative description for the participants.
Plan of Correction:
Participants #2, #3, and #4 now have a photo and a completed narrative description on file at the center.
Standard #:
22VAC40-61-260-A
Description:
Based on the record review the center failed to ensure within 30 days preceding admission, a participant shall have a physical examination by a licensed physician.
Evidence: 1. The record for participant # 4, admission date 3/13/24, contains a physical examination completed on 10/10/23, which is more than 30 days prior to the resident?s admission.
Plan of Correction:
Participant # 4 was discharged prior to inspection, requested updated medical record upon admission, but were not received before discharge. All current participants reviewed and reviewing dates of new participants physical examinations to be within the 30-day window, before the date of first attendance.
Standard #:
22VAC40-61-510-A
Description:
Based on the record review and staff interview the center failed to comply with the Virginia Statewide Fire Prevention Code (13VAC5-51) as determined by at least an annual inspection by the appropriate fire official. Reports of the inspection shall be retained at the center for at least two years.
Evidence: 1. The center?s last fire inspection completed by the fire official is dated 05/11/23. Staff #4 confirmed the center?s most recent fire inspection was completed 05/11/23 and an annual fire inspection has not been completed.
Plan of Correction:
Staff #4 called the Fire Marshall?s Office on 8/6/2024, the day of the DSS Inspection. The Fire Marshall came to do the inspection that same day, 8/6/2024. There were no violations. We are waiting on a copy of the report.
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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