Current Inspector:
Alyshia E Walker
(757) 670-0504
Inspection Date:
Jan. 13, 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 63.2 CRIMINAL PROCEDURES 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION
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: 1/13/2023
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: 28
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: 3
Number of interviews conducted with participants: 1
Number of interviews conducted with staff: 2
Observations by licensing inspector: Licensing Inspector observed participants having snack (fruit and yogurt), several participants did arts and crafts, and participants were utilizing massage chairs and exercise bikes.
Additional Comments/Discussion:
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 observation, the center failed to ensure the posting of the name and telephone number of the appropriate regional licensing administrator of the department; the Adult Protective Services toll-free telephone number; the toll-free telephone number of the Virginia Long-Term Care Ombudsman Program and any local ombudsman program servicing the area; and the toll-free telephone number of the disAbility Law Center of Virginia.
Evidence:
The posted participant rights posted did not include the telephone number for the regional licensing administrator.
Plan of Correction:
The telephone number for the regional licensing administrator was added to the posted participant rights.
Standard #:
22VAC40-61-220-A
Description:
Based upon record review, the facility?s assessment did not include an assessment of the individual?s ambulatory status.
Evidence:
Records for participants #1, #2, #3, #4, #5, and #6 did not include the participants ambulatory ability.
Plan of Correction:
All participants ambulatory ability will be updated to participants? records using VDSS?s Participant Assessment form.
Standard #:
22VAC40-61-230-A
Description:
Based on record review, the facility failed to develop a plan of care prior to or at the time of admission for each participant.
Evidence:
1. Records for participants #1 and #6 did not include a plan of care in the participants records.
2. Staff #3 acknowledged the records for participants #1 and #6 did not include plan of care.
Plan of Correction:
A plan of care will be developed for participants #1 and #6, using VDSS?s Participant Plan of Care (POC) form, and that plan of care will be added to those participants? records.
Standard #:
22VAC40-61-230-D
Description:
Based on records reviewed and staff interviewed, the participant plan of care did not include the expected outcome or goal to be achieved in meeting the assessed needs, the activities and services that will be provided to meet those outcomes or goals, who will provide them, and when they will be provided, the time by which the outcome or goals should be achieved, and the date outcome or goal achieved.
Evidence:
Records for participants #1, #2, #3, #4, #5 and #6 did not include all of the items the Standard requires for the participant Plans of Care.
Plan of Correction:
All participants? plan of care will be updated using VDSS?s Participant Plan of Care (POC) form and will include the expected outcome or goal to be achieved in meeting the assessed needs, the activities and services that will be provided to meet those outcomes or goals, who will provide them, and when they will be provided, the time by which the outcome or goals should be achieved, and date outcome or goal achieved.
Standard #:
22VAC40-61-260-A
Description:
Based on participant records reviewed, the center failed to ensure that participants obtain a physical by a licensed physician within 30 days preceding admission.
Evidence:
Records for participants #1, #2, #3, #4 and #6 did not include physical examinations by a licensed physician.
Plan of Correction:
All participants will obtain a physical by licensed physicians as soon as possible.
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, #2, #3, #4 and #6 did not include documentation of TB evaluations.
Plan of Correction:
All participants will have qualified licensed practitioners complete an assessment for TB in a communicable form as soon as possible.
Standard #:
22VAC40-80-120-E-2
Description:
Based on observation, the center failed to post the findings of the most recent inspection of the facility.
Evidence:
During an inspection of the center with Staff #1 on 01/13/2023, the findings of the most recent inspection of the center was not observed to be posted.
Plan of Correction:
The center has posted a flyer indicating the findings of the most recent inspection of the facility can be found in the administrative office.
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