VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Virginia Home for Boys and Girls
8716 West Broad Street
Henrico, VA 23294
(804) 270-6566

Current Inspector: Dawn Espelage (540) 759-8852

Inspection Date: Dec. 3, 2019 , Dec. 4, 2019 and Dec. 13, 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

Comments:

An unannounced monitoring inspection was conducted on December 3, 2019 from 9:45 a.m. to 4:04 p.m. and on December 4, 2019 from 9:04 a.m. to 4:27 p.m. Eight personnel records, to include background investigation information, were reviewed. Eight personnel records were reviewed against the matrix with no discrepancies. Thirteen residents were in care. Four residents records were reviewed: two current and two discharged resident record. Other documentation reviewed at this inspection included but was not limited to the progress notes, daily communication logs, case management notes, emergency drill documentation, and medication administration records. Interior and exterior physical plant inspections were conducted. The Vice President of Programs, Director of Human Resources, Resource Specialist for Group Care Services, and the Quality Assurance Manager were available to respond to questions. Two residents were interviewed. Exit meeting was held with Staff S1 to discuss preliminary inspection findings before leaving the facility on December 4, 2019. An acknowledgement form was signed at the exit meeting. A desk audit of additional documentation was conducted on December 13, 2019. Exit meeting was held via telephone with Staff S1 on December 18, 2019. 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 resident's record for current resident, CR2, a screening assessment documenting the absence of tuberculosis in a communicable form as evidenced by the completion of a form containing, at a minimum, the elements of a current screening form published by the Virginia Department of Health was not completed. Findings: 1. The record for CR2 contained a "TB Screening Questionnaire" but did not include a TB screening assessment form containing the elements of a current screening form published by the Virginia Department of Health. 2. During an interview with the Licensing Specialist, Staff S4 confirmed that the screening form had not been completed.
Plan of Correction:	Vice President of Programs confirmed with nurse that screening process typically includes an assessment that contains requirement elements. Nurse conducted assessment of CR2 on 12/20/2019 with required elements.
Standard #:	22VAC40-151-640-E
Description:	Violation: Based on review of the record for discharged resident, DR2, the face sheet did not document the required discharge information. Findings: 1. The date of discharge and reason for discharge were not documented on the face sheet. 2. During an interview with the Licensing Specialist, Staff S3 confirmed that this information was missing from the face sheet.
Plan of Correction:	Corrected on site, the discharge information was added to the face sheet during the inspection. Observed by the Licensing Specialist.
Standard #:	22VAC40-151-640-E
Description:	Violation: Based on review of the record for discharged resident, DR2, the face sheet did not document the required discharge information. Findings: 1. The date of discharge and reason for discharge were not documented on the face sheet. 2. During an interview with the Licensing Specialist, Staff S3 confirmed that this information was missing from the face sheet.
Plan of Correction:	Corrected forms on site