VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Alpha House II
3903 West Autumn Drive
Petersburg, VA 23803
(804) 861-0533

Current Inspector: Irvin Goode (804) 543-5188

Inspection Date: Sept. 18, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-151 22VAC40-151 III. RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCEY PLANNING

Technical Assistance:

Discussed the interior of the building as noted in standard 520.B. Discussed the protection needs of the resident as noted in standard 620.B.4. Discussed the legal guardian in relation to the individualized support plans as noted in standard 800.B.2.

Comments:

An unannounced monitoring inspection was completed by the Licensing Specialist on 9/18/19 from 10:40 a.m. to 4:45 p.m. and 9/20/19 from 10:04 a.m. to 4:36 p.m. The current census is three (3) residents. The following is a listing of the activities for this inspection: Reviewed one current resident record and one discharged resident record. Reviewed two medication administration records. Four personnel records, which includes two new staff members hired since the May 2019 monitoring inspection, were reviewed. No discrepancies were found with the CRF matrix. One staff and one resident were interviewed. An inspection of the interior and exterior of the facility was completed. Other documentation reviewed during this inspection included, but was not limited to the following: emergency drill documentation, menus, and staff work schedules. The Program Director was available and accessible during the inspection. An Exit Interview to review preliminary findings was conducted with the Program Director at approximately 2:19 p.m. on 9/20/19. The Acknowledgement of Inspection form was signed and left at the facility. Upon receipt of this violation notice, a plan of correction is requested for each violation. The Plan of Correction should include, as appropriate: - steps to correct noncompliance of a regulation, - measures to prevent reoccurrence of noncompliance, - person(s) responsible for implementing each step and/or monitoring any preventive measure(s), and - the date by which the noncompliance will be corrected. Be advised that the Violation Notice, including the Plan of Correction and this Summary page will be posted on the VDSS web page and available for review by the general public. Do not write any names or other confidential information into your plan of correction.

Violations:

Standard #:	22VAC40-151-190-B-2
Description:	Violation: Based on review of a personnel record and interview with staff, the facility failed to document annual results of a screening assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the form. Findings: 1) The personnel record for S1 contains a tuberculosis screening form dated 6/17/19. a. This document does not contain all the required elements. It does not provide the results for this assessment. i. Neither of the following options were checked on this document - ?Further testing NOT required? and ?Further testing IS required.? 2) S5 reviewed the form during the exit interview. S5 confirmed that the screening assessment did not contain the results of the assessment.
Plan of Correction:	All TB screening forms will be reviewed by the Director more carefully for missing documentation on the form before the form is filed in the employees personnel record. Effective 10/3/19 under oversight of Director.
Standard #:	22VAC40-151-680-E
Description:	Violation: Based on review of the record for discharged resident, DR1, and interview with staff, the facility failed to include information concerning current medications, need for continuing therapeutic interventions, educational status, and other items important to the resident?s continuing care shall be provided to the legal guardian or legally authorized representative, as appropriate. Findings: 1) The Licensing Specialist reviewed the ?Discharge Info.? document in DR1?s record. 2) The Licensing Specialist asked S5 if this form is being used to document compliance with 22 VAC 40-151-680.E. a. S5 confirmed it is used for this particular standard. 3) The following elements are missing from the ?Discharge Info.? document a. Current medications b. The need for continuing therapeutic interventions c. Educational Status
Plan of Correction:	The Director shall immediately begin using the VA DSS form for discharge information for guardians for all discharge residents. Effective 10/3/19 with oversight of Director.
Standard #:	22VAC40-151-750-E
Description:	Violation: Based on review of the current resident?s, CR1?s, medication administration record and interview with staff, the facility failed to demonstrate medication was administered as prescribed. Findings: 1) The medication administration record (MAR) has a box for staff to initial for each day of the month that medication is given. 2) The MAR for August 2019 shows an empty box for the following date: a. Medication, M1, on 8/30/19. 3) S5 reviewed the MAR for August 2019 for CR1 and confirmed the box was empty. 4) S5 agreed with the Licensing Specialist?s findings.
Plan of Correction:	Medication administration signature was missing for one of the medications prescribed to a resident. In reviewing the medication administration log it appears staff administered all other medications but missed signing this particular signature page. Staff were reminded 10/3/19 to check behind one another shift to shift and question blanks in the medication log to ensure medication administration is correctly administered. Staff are reminded to take their time when documenting medication administration and complete all documentation or medication error forms as required. Effective 10/3/19 with oversight of the Director.