Current Inspector:
Marshall Massenberg
(804) 543-5188
Inspection Date:
May 23, 2024
Complaint Related:
No
Areas Reviewed:
General Provisions Administration Personnel Supervision Admission, Retention and Discharge Programs and Services Building and Grounds 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: 05/23/2024 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: 53 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 6 Number of staff records reviewed: 6 Number of interviews conducted with participants: Number of interviews conducted with staff: 2 Observations by licensing inspector: Licensing Inspector observed residents participating in activity programs and eating lunch. Additional Comments/Discussion:
An exit meeting was 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 Sarah Pearson, Licensing Inspector at (540) 680-9469 or by email at sarah.pearson@dss.virginia.gov
Based on staff record review and staff interview, the facility failed to ensure the director completed 24 hours of continuing education training annually. Evidence: 1. Staff 1, hired on 3/11/2014, had 12 hours of continuing education recorded on the day of inspection on 5/23/2024. 2. Staff 1 stated she was not aware that 24 hours of continuing education training was required annually for the director.
Plan of Correction:
With the corrected understanding of the continued education training required for the director, Staff 1 immediately completed an additional 13 hours of continued education training on 5/23/2024 and 5/24/2024. Moving forward, the director will complete 24 hours of continued training annually and documentation of said training will be included in the director?s employee file.
Standard #:
22VAC40-61-260-B
Description:
Based on participant record review and staff interview, the facility failed to complete an assessment for tuberculosis no earlier than 30 days before admission. Evidence:
1. Participant 1, who was admitted on 2/29/2024 had a Report of TB Screening completed on 3/8/2024. 2. Participant 2, who was admitted on 10/31/2023, had a Quantiferon-TB Gold Plus screening completed on 12/8/2023.
3. Participant 3, who was admitted on 2/6/2023, had a Report of TB Screening completed on 2/24/2023.
4. Participant 6, who was admitted on 2/29/2024, had a chest x-ray completed on 3/11/2024.
Plan of Correction:
We have revised our system for admitting new members to include a clearly defined process, timeline and checklist to ensure, moving forward, all requirements are met prior to a member?s admission at Love Hand?s center.
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