VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Saving Families Group Home - Najai's House
8903 Sonnet Hill Court
Richmond, VA 23236
(804) 276-1454

Current Inspector: Irvin Goode (804) 543-5188

Inspection Date: Feb. 14, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-151 INTRODUCTION. 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 02/14/2022 from 9:43 a.m. to 2:26 p.m. Two personnel records, to include background investigation information, were reviewed. The requirement to complete a CRF Employee Matrix was discussed. Two residents were in care. Two residents records were reviewed. Other documentation reviewed at this inspection included but was not limited to the daily log, case management notes, emergency drill documentation and automated medication administration records. The physical plant inspection was conducted. Administrator A1 was present and available to respond to questions. Exit meeting was held with A1 to discuss preliminary inspection findings before leaving the facility on February 14, 2022. An acknowledgement form was signed at this exit meeting. The licensee has five (5) calendar days from receipt of the inspection documentation to sign each page of the documentation and return it to the Licensing Office. 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.

Violations:

Standard #:	22VAC40-151-660-B-6
Description:	Violation Based on review of the 01/06/2022 service plan completed for resident, R1 and interview with administrator A1, status of the projected discharge plan and estimated length of stay were not documented. Findings: 1. The response to the status of discharge plan and estimated length of stay was documented as "unknown". 2. Interview with administrator A! confirmed the responses to these required elements of the service plan.
Plan of Correction:	The Program Director and Case Manager has been educated on the elements of the service plan. Program Director and Case Manager were made aware that all elements must be filled out in its entirety and ?unknown? is not acceptable. The service plan should be reviewed by a third person, either the house manager or CEO, to verify accuracy
Standard #:	22VAC40-151-720-E
Description:	Violation: Based on review of the daily log for residents R1 and R2, the identity of the person making each entry in the daily communication log was not recorded for two entries. Findings: 1. Resident R1: the identity of the individual making the entry during the night shift on 01/20/2022 was not documented in the daily communication log. 2. Resident R2: the identify of the individual making the entry during the day shift on 01/28/2022 was not documented in the daily communication log.
Plan of Correction:	The daily communication log and hourly check documentation will be reviewed by the staff on the following shift for missing initials and/or signatures and a note will be left in the office. The house manager will review the daily communication log and hourly check documentation on a weekly basis, prior to the documents being scanned into sharepoint.
Standard #:	22VAC40-151-730-B
Description:	Violation: Based on review of the residents records for resident R1 and resident R2 and interview with administrator, A1, written information concerning each resident was not readily accessible in the event of a medical or dental emergency. Findings: 1. Resident R1: name, address, and phone number of the physician to be notified in the event of an emergency were not documented. 2. Resident R2: name, address, and phone number of the dentist to be notified in the event of an emergency were not documented. 3. A1 confirmed that the required information was not documented and therefore was not readily accessible in the event of a medical or dental emergency.
Plan of Correction:	Night shift DSP Staff will update the health care procedures form after each resident?s appointment, to ensure that the required physician, dentist, therapist, psychiatrist information is up to date. The house manager will review the health care procedures documents every Monday to certify that the resident?s emergency information is accurate and readily accessible
Standard #:	22VAC40-151-740-A
Description:	Violation: Based on review of the resident's record for resident R1 and interview with administrator A1, the initial physical examination was not completed within the required seven day timeframe. Findings: 1. The initial physical examination was due to be completed by 12/20/2021 but was not completed until 01/13/2022. 2. A1 acknowledged the physical examination was not completed within the required seven day timeframe.
Plan of Correction:	The house manager will check the resident?s documentation on the day of arrival to identify if the resident has all required elements of a physical completed within the last 12 months if coming from another facility, otherwise the house manager will call the doctor?s office to schedule an appointment no later than the next business day with an appointment no more than 7 days away
Standard #:	22VAC40-151-740-E-1
Description:	Violation: Based on review of the resident's record for resident R2 and interview with administrator A1, the initial physical examination did not include all of the required elements. Findings: 1. The 01/28/2022 initial physical examination report did not include the following required elements: - allergies, chronic conditions, handicaps, if any; - nutritional requirements, including special diets, if any; - restrictions on physical activities, if any; and - recommendations for further treatment, immunizations, and other examinations indicated. 2. A1 confirmed that the section of the physical examination report that included the above required elements had been left blank by the physician.
Plan of Correction:	Staff that is escorting the resident to appointments to check that all elements are complete prior to leaving the appointment. The house manager will review all healthcare appointment documents within 48 hours for accuracy
Standard #:	22VAC40-151-960-B-5
Description:	Violation: Based on review of the resident's record for resident R2 and interview with administrator A1, the serious incident report did not include the name of the person to whom the report was made. Findings: 1. Review of the serious incident report on file for R2 did not include the name of the person to whom the report was made. 2. A1 acknowledged that this required element was missing from the serious incident report.
Plan of Correction:	The Program Director, Case Manager, House Manager, and DSP Staff was educated on the elements of the form. All staff was informed that the element on the report ?the name of the person to whom the report was made? is to place the name of the person that the actual report is being reported to, ie Parent, legal guardian, placing agency