VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Seton House Youth Shelter
465 Kings Grant Road
Virginia beach, VA 23452
(267) 973-1144

Current Inspector: Sherry Woodard (757) 987-0839

Inspection Date: Nov. 6, 2019 and Nov. 7, 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 22VAC40-151 SPECIAL PROGAMS

Comments:

An unannounced monitoring inspection was conducted on November 6, 2019 from 11:07 a.m. to 4:45 p.m. and on November 7, 2019 from 9:00 a.m. to 4:01 p.m. Eight personnel records, to include background investigation information, were reviewed. Eight personnel records were reviewed against the matrix. Six residents were in care at the time of the inspection. Two residents records were reviewed: one current and one discharged resident record. Other documentation reviewed at this inspection included but was not limited to the daily log, case management notes, emergency drill documentation, and medication administration records. Interior and exterior physical plant inspections were conducted. Staff S3 assisted with the internal physical plant inspection. Staff S1 was available to respond to questions during the inspection. Two residents present during the inspection declined to be interviewed. Exit meeting was held with Staff S1 to discuss preliminary inspection findings before leaving the facility on November 7, 2019. An acknowledgement form was signed at the exit meeting. Please complete the plan of correction and date to be corrected for each violation cited on the violation notice and return to the Licensing Office within 5 business days from receipt of the inspection documentation. You will need to specify how the deficient practice will be or has been corrected (merely writing the word corrected is not acceptable). Your plan of correction must contain the steps to correct the noncompliance with the standard(s), the measures to prevent the noncompliance from occurring again; and the position responsible for implementing each step and/or monitoring any preventive measure(s). The licensee should retain a copy to be posted at the facility. Results of the inspection documentation are subject to public disclosure and will be posted on the VDSS web site within 5 days, regardless of whether the Plan of Correction is completed.

Violations:

Standard #:	22VAC40-151-190-B-1
Description:	Violation: Based on review of the personnel record for Staff S6 and interview with Staff S1, the Tuberculosis (TB) screening assessment was not completed within the required timeframe. Findings: 1. The TB screening assessment was not completed within 30 days of the time of hire for S6. 2. During an interview with the Licensing Specialist, S1 confirmed that the TB screening assessment was older than 30 days.
Plan of Correction:	Staff TB testing was not completed within the 30 day timeframe during the hiring process. Going forward Director and Assistant Director will ensure TB testing for new hires is completed within the 30 day time limit. Should a new hire present with TB test earlier than the 30 day limit then they will be required to retake their TB Test.
Standard #:	22VAC40-151-730-B-4-a
Description:	Violation: Based on review of the resident's readily accessible medical emergency information for current resident CR1 and interview with Staff S1, use of medication was not accurately documented. Findings: 1. CR1's list of medication in the emergency medical information was not current. 2. During an interview with the Licensing Specialist, Staff S1 confirmed that the medication was not current.
Plan of Correction:	Up to date MAR sheets have been included into resident Grab-n-Go packets and will be updated as changes to medications occur. Director/Assistant Director will review all Grab-n-Go packets to ensure they are up to date and Youth Care Worker Staff will be responsible for putting Grab-n-Go packets together.