Current Inspector:
Alyshia E Walker
(757) 670-0504
Inspection Date:
June 28, 2023
Complaint Related:
No
Areas Reviewed:
22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 ADMISSION, RETENTION AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUND 22VAC40-80 THE LICENSE
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: 6/28/2023
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: 2
The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility.
Number of participant records reviewed: 2
Number of staff records reviewed: 1
Number of interviews conducted with participants: 2
Number of interviews conducted with staff: 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 Alyshia E. Walker, Licensing Inspector at 757-670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Based on a review of staff records, the center failed to ensure that each staff person shall obtain initial tuberculosis (TB) examination and report.
Evidence:
The record for Staff # 1 did not contain documentation of an initial TB screening.
Plan of Correction:
Staff TB appointment has been scheduled.
Standard #:
22VAC40-61-230-D
Description:
Based on review of participant records, the center failed to ensure that each participant's plan of care contained a description of all needs identified on the participant assessment.
Evidence:
1. The record for Participant # 1 contained an assessment dated 4/11/23 that identified the following needs requiring assistance: walking, climbing stairs, bathing, dressing, transferring, and eating. However, the participant's plan of care dated 4/24/23 did not address those needs.
2. The record for Participant # 2 contained an assessment dated 5/23/23 that identified the following needs requiring assistance: bathing, dressing, toileting, and transferring. However, the participant's plan of care dated 5/23/23 did not address those needs.
Plan of Correction:
All Plans of Care have been updated to match and address all needs.
Standard #:
22VAC40-61-240-A
Description:
Based on record review, the facility failed to ensure at or prior to the time of admission, there be a written agreement between the participant and the center. The agreement shall be signed and dated by the participant or legal representative and the center representative.
Evidence:
Participant 2 was admitted on 5/23/2023 and the agreement was signed on 5/31/2023.
Plan of Correction:
All agreements are signed and ongoing agreements will be signed day of admission.
Standard #:
22VAC40-61-260-B
Description:
Based on participants records reviewed, the facility failed to ensure that participants obtained an evaluation by a qualified licensed practitioner that completed an assessment for tuberculosis (TB) in a communicable form no earlier than 30 days before admission.
Evidence:
Records for participants #1 and #2 did not include documentation of TB evaluations.
Plan of Correction:
Care takers have scheduled appointments for TB screenings to be completed.
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