VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Tina's World of Love
1751 Church Street
Suite C
Norfolk, VA 23504
(757) 500-4306

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: June 4, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-60 PERSONNEL. 22VAC40-60 SUPERVISION. 22VAC40-60 BUILDINGS AND GROUNDS. 22VAC40-60 ADMISSION, RETENTION AND DISCHARGE. 22VAC40-60 PROGRAMS AND SERVICES. 22VAC40-60 EMERGENCY PREPAREDNESS. 22VAC40-80 THE LICENSE.

Technical Assistance:

Please check the web site often for updates and information. Also please register for the upcoming Emergency Preparedness training on 6-26-19.

Comments:

An unannounced monitoring inspection was conducted on this date from 10:48a.m until 2:05 p.m. There were three participants present . Eight participants are enrolled. Two direct care staff and the program director and assistant director were present. Eight participant records and two staff records were checked. Observed the posted catered lunch meal of meat loaf, mashed potatoes and greens. Also observed the posted twisted Tuesday game /the participants guessed what picture the . staff drew on the board . All participants actively participated . The first aid kit was checked . Currently no medications are administered at the the center. There was discussion about the content of the care plan. Please complete the ?plan of correction? for each violation cited on the violation notice and return it to me within 10 calendar days from today on 6-14-19 You will need to specify how the violation will be or has been corrected. Just writing the word ?corrected? is not acceptable. Your plan of correction must include: 1. steps to correct the noncompliance 2. measures to prevent reoccurrences 3. Person(s) responsible for implementing and monitoring each step of the corrective measures and / or the preventative measures

Violations:

Standard #:	22VAC40-60-564-A
Description:	Based on record review and interview the center failed to secure a written assessment on six of the eight participants prior to admission. Evidence 1. During review of the participants records with staff #1 and#2 the inspector found the following: a. participant # 3 admitted 5-6-19, had a written assessment dated 3-29-14 b. participant # 4 admitted 4-23-19, had a written assessment dated 8-9-14 c. participant # 5 admitted 4-8-19, had a written assessment dated 5-10-17 d. participant #6 admitted 4-17-19, had a written assessment dated 12-31-11 e. participant #7 admitted 4-1-19, had a written assessment dated 4-22-15 f. participant #8 admitted 2-19-19, had a written assessment dated 10-30-08 2. The assessments observed on file range from 2 years to 11 years old and did not reflect all of the participants' current functional abilities.. 3. Staff #2 stated during interview the assessments had been completed prior to the participants admission but were not based upon the information obtained from the participant or the family prior to admission , or the physical exam required and completed 30 days prior to admission.
Plan of Correction:	Effective immediately all incoming participants will have an up to date UAI. Director will touch base with all the City Social Services offices to gain a contact person to refer participants to, so they can obtain and up to date Assessment and a every six month assessment
Standard #:	22VAC40-60-600-A
Description:	Based on record review and interview the facility failed to ensure two of the eight participants enrolled had a physical examination by or under the direction of a licensed physician either within 30 days prior to acceptance for admission or within 30 days prior to admission. Evidence 1. During review of the participants records with staff # 1 and #2 , the inspector found participant #2 admitted 4-12-19 had a physical exam last year on 6-28-18 and resident # 6 accepted for admission on 2-1-19 had a physical exam after acceptance on 2-19-19. 2. Staff #2 acknowledged the physical exams were not completed within the required timeframe.
Plan of Correction:	All incoming participants will have physical w/n 30 days of admission or a written statement they had a physical and their condition hasn't changed or Dr's update their information in writing.