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: April 6, 2022 and April 18, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-151 Administration 22VAC40-151 Residential Environment 22VAC40-151 Programs and Services 22VAC40-151 Programs and Services 22VAC40-151 Disaster or Emergency Planning

Technical Assistance:

Discussed washcloths and towels as noted in CRF standard 22 VAC 40-151-410.B.

Comments:

An unannounced monitoring inspection was completed by the Licensing Specialist on 4/6/22 from 9:55 a.m. to 5:39 p.m., 4/7/22 from 9:30 a.m. to 5:02 p.m., and 4/8/22 from 11:15 a.m. to 12:21 p.m. The current census is four (4) residents. The following is a listing of the activities for this inspection: Reviewed one current resident record and one discharged resident record. Reviewed medication administration records. Two personnel records were reviewed. No discrepancies were found with the CRF matrix. Two staff members and three residents 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 on 4/6/22 and 4/8/22. The Team Leader was available and accessible during the inspection on 4/7/22. The Program Director participated in the preliminary findings meeting held at the facility on 4/8/22. The Acknowledgement of Inspection form was signed and left at the facility on each date. The Program Director was also interviewed by phone on 4/15/22. 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 the personnel record for staff, S1, 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 does not contain a current screening assessment. 2) S3 acknowledged that a current screening assessment is not in S1?s personnel record.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-730-B-1
Description:	Violation: Based on review of the facility?s readily accessible written information for current resident, CR1, and interview with staff, the facility failed to include the name, address, and telephone number of the dentist to be notified if staff have to respond to a dental emergency. Findings: 1) The name, address, and phone number for the dentist are missing from CR1?s Emergency Medical Care Plan, which is stored in the facility?s readily accessible binder. 2) S3 acknowledged the information was missing.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-740-D
Description:	Violation: Based on review of current resident?s, CR1?s, health record and interview with staff, the facility failed to include written documentation of the provision of follow-up medical care recommended by the physician or as indicated by the needs of the resident. Findings: 1) CR1?s record contained a physical examination report dated for 12/8/21, which states the following in the ?Further Treatment? section ? ?Continue to follow w/eye doctor.? 2) The doctor?s notes in regard to CR1?s vision in the right eye states the following--?unable -> blind.? 3) Upon review of CR1?s record, there was no written documentation that CR1 had been seen by an eye doctor. 4) CR1 was interviewed about her eyes. She shared there is an issue with her optic nerve in the right eye. 5) S3 was interviewed about this matter. She acknowledged that CR1 has not been seen by an eye doctor.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-750-E
Description:	Violation: Based on review of current resident?s, CR2?s, medication administration record and interview with staff, the facility failed to demonstrate medication, M1, was administered as prescribed. Findings: 1) The medication administration record (MAR) has a box for staff to initial and note the time for each day of the month that medication is given. 2) The MAR for March 2022 shows empty boxes for the following dates: 3/20, 3/21, 3/23-3/28, and 3/31. 3) The MAR also states the following ? ?Wash and apply cream daily for 2 week (sic) if no reaction apply 2 times daily.? a. Upon review of the MAR, M1 was not administered for two weeks or 14 days. It was administered for twelve days. b. Also, there is no indication on the MAR if there was a reaction to this medication after two weeks. Yet, it was provided after the two week period on three separate dates. However, after two weeks, it should have been administered ?two times daily? if there was no reaction. 4) S3 acknowledged the medication was not administered as prescribed.
Plan of Correction:	Not available online. Contact Inspector for more information.
Standard #:	22VAC40-151-750-F-5
Description:	Violation: Based on review of the medication administration record (MAR) for current resident, CR2, and interview with staff, the facility failed to maintain all medicines received by the resident, which includes the route. Findings: 1) CR2 was prescribed M1, a facial cream used to treat acne. 2) Upon review of the MAR, the route documented for this medication states ?oral,? which is incorrect. The MAR states M1 should be administered by doing the following - ?Wash and apply cream daily for 2 week (sic) if no reaction apply 2 times daily.?
Plan of Correction:	Not available online. Contact Inspector for more information.