Current Inspector:
Marshall Massenberg
(804) 543-5188
Inspection Date:
March 8, 2022
Complaint Related:
No
Areas Reviewed:
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 GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE. 22VAC40-80 THE LICENSING PROCESS. 22VAC40-80 SANCTIONS. 63.2 General Provisions. 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 63.2(19.2) Criminal Procedures. 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report
Comments:
An unannounced renewal study was conducted on 3/8/2022. At the time of entrance 36 participants were present with six center staff. This meets the required ratio of one staff per six participants. The sample size consisted of six participant records and three staff records. No new staff have been hired since the previous inspection conducted on 11/9/2021. No medications were administered during the inspection. Activities included exercise, arts & crafts, outdoor walk and board games. Interviews were not conducted as the participants? first language is not English and no interpreters were provided. The violations were reviewed during the exit interview held with Director.
Thank you for your cooperation and if you have any questions please call 703-479-4708 or contact me via email at lynette.storr@dss.virginia.gov.
Center failed to ensure that each direct care staff member shall 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. The certification must either be in adult first aid or include adult first aid. To be considered current, the certification shall have been issued within the past three years.
Evidence: Staff #1and Staff #3 do not have documentation of current First Aid Training.
Plan of Correction:
Center will arrange for all staff to have updated First Aid Training.
Standard #:
22VAC40-61-180-E-1
Description:
Center failed to ensure that each staff person and volunteer identified in this subsection shall obtain an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis in a communicable form no earlier than 30 days before or no later than seven days after employment or contact with participants.
Evidence: Staff #3's TB screening is dated 11/21/2019, this is outside the required trimeframe.
Plan of Correction:
Center Director will ensure that all staff have updated TB screenings.
Standard #:
22VAC40-61-250-B
Description:
Center failed to ensure that the required personal information shall be kept current for each participant.
Evidence: Participants #1, 2, 3, 4, 5, and 6 did not include all of the required personal information. The required information was reviewed the Administrator and it was confirmed that all of the required information was not documented.
Plan of Correction:
Administrator will create a form and update all of the participant records.
Standard #:
22VAC40-61-260-A
Description:
Center failed to ensure that the physical examination included the date of the physical examination and a list of all medications including dosages, route, and frequency of administration.
Evidence: Participants #2, 4 and 5 did not include the date of the physical examination on the examination form. Participants #4 & 5 examinations indicated that a medication list was attached however the list was not attached.
Plan of Correction:
Center Director to review all participant records to ensure that the physical examination is completed in its entirety.
Standard #:
22VAC40-61-540-A
Description:
Center failed to ensure that fire and emergency evacuation drill frequency and participation shall be in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51).
Evidence: There is no documentation to indicate that fire drills were conducted in the past year. Staff interview confirms that fire drills ere not conducted.
Plan of Correction:
Center will use DSS model form to record fire drills quarterly on each shift.
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