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
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: 10/30/23 from 8:51am to 12:00pm
The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. (emailed)
Number of participants present at the facility at the beginning of the inspection: 16
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: 4
Number of interviews conducted with staff: 3
Observations by licensing inspector: Licensing Inspector observed participants having a morning snack, activities, and lunch.
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 Walker, Licensing Inspector at (757)670-0504 or by email at Alyshia.Walker@dss.virginia.gov
Based on record review, the center failed to ensure staff who are primarily responsible for direct care of the participants attend at least 12 hours of training annually.
Evidence:
The staff record for Staff #2 contained documentation of 5.25 hours of training. The staff record for Staff #3 contained documentation of 7.46 hours of training, and the staff record for Staff #4 contained documentation of 10.20 hours of training.
Plan of Correction:
1. Director of Adult Day Services/designee will educate by 12/22/23 staff #2 and staff #4 of the requirement that 12 hours of continuing education is required based on anniversary date and any training attended outside the organization must be turned into director. Staff #3?s last day at the center was 12/14/23.
2. An audit of all staff training records will be completed by the Director of Adult Day Services/designee by 12/31/23 to ensure the 12-hour annual training requirement is met for all current team members.
3. The Director of Adult Day Services/designee will ensure all outside organizational trainings will be recorded within the internal training transcript within a month of receiving certificates from training organizations. The Director of Adult Day Services/designee will create a process for tracking training hours by anniversary date to ensure team members are compliant with required training prior to being scheduled.
4. A monthly audit of staff training hours will be conducted for three months by the Director of Adult Day Services/designee to make certain all staff members are on target to complete their required 12 hours of annual training.
5. All actions will be completed by 12/31/23.
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