Current Inspector:
Margaret T Pittman
(757) 641-0984
Inspection Date:
May 4, 2023
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 GROUND 22VAC40-61 EMERGENCY PREPAREDNESS
Technical Assistance:
22VAC40-61-160 22VAC40-61-230
Comments:
Type of inspection: Renewal Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/04/2023 at 9:15 am to 10:15 am. 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: 0 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 1 Number of staff records reviewed: 2
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 center failed to ensure staff who provide direct care to participants attend at least 12 hours of training annually. The required hours of training shall be in addition to first aid, CPR, orientation, or initial or refresher medication aide training.
Evidence:
1. Upon review of staff records, Staff #2 and Staff #3 did not complete at least 12 hours of training annually in 2022.
Plan of Correction:
Staff #2 and Staff #3 has completed the required hours for first aide and 12 hours annually training for year 2022.
Standard #:
22VAC40-61-520-C
Description:
Based on discussion, the center failed to develop and implement an orientation and semi-annual review on the emergency preparedness and response plan for all staff, participants, and volunteers with emphasis placed on an individual's respective responsibilities, except that for participants, the orientation and review may be limited to only subdivisions 1 and 2 of this subsection. The review shall be documented by signing and dating.
Evidence:
1. Staff #1 did not have documentation of staff?s semi-annual review on the emergency preparedness and response plan.
Plan of Correction:
Staff#1 has sign documentation of staff's semi-annual review on the emergency preparedness and response plan.
Standard #:
22VAC40-61-520-D
Description:
Based on discussion, the center failed to document the review of the emergency preparedness and response plan annually or more often as needed by signing and dating the plan and make necessary revisions. Such revisions shall be communicated to staff, participants, and volunteers and incorporated into the orientation and semi-annual review.
Evidence:
1. Staff #1 did not have documentation of a review of the emergency preparedness and response plan annually or more often as needed.
Plan of Correction:
Staff#1 has review and sign the emergency preparedness response plan for annually.
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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http://www.dss.virginia.gov/facility/search/adc.cgi