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: Sept. 15, 2022 and Sept. 16, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-151 INTRODUCTION 22VAC40-151 ADMINISTRATION 22VAC40-151 RESIDENTIAL ENVIRONMENT 22VAC40-151 PROGRAMS AND SERVICES 22VAC40-151 DISASTER OR EMERGENCY PLANNING

Comments:

Type of inspection: Monitoring. Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 09/15/2022 10:32 a.m. to 3:36 p.m. and 09/16/2022 10:04 a.m. to 12:25 p.m. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of residents in care at the beginning of the inspection: 3. The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of resident?s records reviewed: 1. Number of staff records reviewed: 4. Number of interviews conducted with staff: 1. Observations by licensing inspector: discussed the damaged office door (confidential conversations). Additional Comments/Discussion: discussed electronic records systems (all documentations must be included in the electronic records system). An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit meeting. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov. Should you have any questions, please contact Connie McHale, Licensing Inspector at (804) 662-7084 or by email at connie.mchale@dss.virginia.gov

Violations:

Standard #:	22VAC40-151-240-B-10
Description:	Based on review of the personnel record for Staff S4 and interview with administrator A1, a job description was not documented in the personnel record. Findings: 1. A job description was not included in the personnel record. 2. A1 confirmed that a job description was not included in the personnel record.
Plan of Correction:	Chief Administrative Officer will review all required personnel files after Program Director has selected candidate. Once the file has been reviewed and approved by the Chief Administrative Officer, the file will be forwarded to the Chief Executive Officer for a second approval. If there are any missing required documents, the candidate will not be able to begin employment or will be taken off duty until all documents are received.
Standard #:	22VAC40-151-240-B-3
Description:	Based on review of the personnel records for staff S2, S3, and S4 and interview with administrator A1, written references or documentation of oral references were not documented. Findings: 1. References were not included in the personnel records. 2. A1 confirmed that references were not documented.
Plan of Correction:	Chief Administrative Officer will review all required personnel files after Program Director has selected candidate. Once the file has been reviewed and approved by the Chief Administrative Officer, the file will be forwarded to the Chief Executive Officer for a second approval. If there are any missing required documents, the candidate will not be able to begin employment or will be taken off duty until all documents are received.
Standard #:	22VAC40-151-660-B-5
Description:	Based on review of the resident?s record for resident R1 and interview with administrator A1, the projected date for accomplishing each objective was not documented in the service plan. Findings: 1. The service plan did not include the projected dates for accomplishing each objective. 2. A1 confirmed that the dates were not documented in the service plan (left blank).
Plan of Correction:	In the creation of the service plan, the Program Director will be sure to list the projected dates for accomplishing each objective. Once this has been completed, the document will be forwarded to the Chief Administrative Officer for review and approval. The Chief Executive Officer will review records for accuracy on a monthly basis and will require that an missing elements be completed within 48 hours.
Standard #:	22VAC40-151-660-H
Description:	Based on review of the resident?s record for R1 and interview with administrator A1, participation or involvement in the service plan by the required parties was not documented. Findings: 1. Participation or involvement in the development of the service plan by the resident?s legal guardian, placing agency, and family (if appropriate) was not documented. 2. A1 acknowledged that the participation was not documented.
Plan of Correction:	Program Director will be responsible for printing communication for the development of service plans prior to filing the reports. If the communication was held via treatment teams meeting, the Program Director will be responsible for taking notes for the meeting acknowledging participants.
Standard #:	22VAC40-151-730-B-1
Description:	Based on review of the readily accessible medical emergency information for resident R1 and interview with administrator A1, the required information was not documented. Findings: 1. The name, address, and phone number of the physician and dentist to be notified in the event of an emergency were not documented in the readily accessible medical emergency information. 2. A1 acknowledged that this information was not documented in the readily accessible medical emergency information.
Plan of Correction:	Overnight staff will be responsible for ensuring readily accessible medical emergency information is current and up to date. On a weekly basis, this information will be reviewed by the House Manager for accuracy. Once this has been reviewed, a checklist will be signed and submitted to the Program Director for review. On a monthly basis, these records will be reviewed by the Chief Administrative Officer to ensure protocols are being followed.