VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Adult Day Services by Primeplus Senior Centers
7300 Newport Avenue
Suite 100
Norfolk, VA 23505
(757) 625-5857

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

Inspection Date: Sept. 12, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-60 PERSONNEL. 22VAC40-60 ADMISSION, RETENTION AND DISCHARGE.

Comments:

This was an unannounced renewal inspection conducted by a Licensing Inspector from the Eastern Regional Office. The inspection was conducted on September 12, 2019 from 10:30 am until 3:23 pm. There were 13 participants and 4 staff present. During the inspection, a tour of the center was conducted. A card game and a music activity were observed. Lunch was observed as posted on the menu to include baked fish, rice pilaf, spinach, bread, and mandarins. A medication pass observation was also conducted. Participant and staff records were reviewed. There were no new staff since the previous inspection. Observed construction taking place on the back patio/courtyard. The center received violations in the areas of Personnel and Admission, Retention and Discharge. The violations cited were reviewed with the center's nurse, who was present on behalf of the Director, during the exit interview. During the inspection, discussed reviewing all forms for accuracy and completeness, discussed staff training options, and documentation of health monitoring information. Please complete the "plan of correction" and "date to be corrected" for each violation cited on the violation notice. The plan of correction should include 1. Step(s) to correct the noncompliance with the standard 2. Methods to prevent re-occurrence and, 3. Person(s) responsible for implementing and/or monitoring each step.

Violations:

Standard #:	22VAC40-60-235-C-2-c
Description:	Based on record review and interview, the center failed to ensure a tuberculosis (TB) test was completed annually for one out of three staff in the record sample. Evidence: 1. During review of staff records, staff #2 did not have a recent TB test on file. The most recent TB test in the record was dated 8-25-18. 2. During interview, staff #1 stated that staff #2 acknowledged she did not have a more recent TB test.
Plan of Correction:	Staff # 2 was made aware of her violation and went to Velocity Care on Granby Street and Little Creek Road on 9/13/2019. Both centers were out of the Serum and told her they should have more in stock on October 7,2019. She went to Velocity Urgent Care in Virginia to have her TB test administered on 10/7/2019.
Standard #:	22VAC40-60-300
Description:	Based on record review and interview, the center failed to ensure staff who are primarily responsible for direct care of the participants attend at least eight contact hours of staff development activities which consist of in-service training programs, workshops, or conferences relevant to the needs of the population in care. These staff development activities shall be in addition to first aid, CPR, or orientation training. Evidence: 1. During review of staff records, the following staff did not have at least 8 hours of documented annual training, in addition to first aid, CPR, or orientation training: a. Staff #2's date of employment was 8-27-18. Staff #2 did not have any hours of annual training documented for the period of 8-27-18 to 8-27-19. b. Staff # 3's date of employment was 4-30-18. Staff #3 had 2 hours of documented training for the period of 4-30-18 to 4-30-19. c. Staff #4's date of employment was 4-6-96. Staff #2 had 2 hours of documented training for the period of 4-6-18 to 4-6-19. 2. During interview staff #1, #3, and staff #4 acknowledged there was no documentation of additional training completed for staff #2, #3, and #4 at the time of inspection.
Plan of Correction:	Staff #2 had 4 hours of CEU that were not posted in the binder. A copy of that training is in this packet of corrections. The employee had been made aware of the seriousness of this violation and will be required to finish 4 CEU?s by October 12 or her job will be compromised. The A.D.S. Director will monitor the CEU notebook. Staff #3 had 4 hours of CEU that were not posted in the binder. A copy of that training is in this packet of corrections. The employee had been made aware of the seriousness of this violation and will be required to finish 2 CEU?s by October 12 or her job will be compromised. The A.D.S. Director will monitor the CEU notebook. Staff #4 had 4 hours of CEU that were not posted in the binder. A copy of that training is in this packet of corrections. The employee had been made aware of the seriousness of this violation and will be required to finish 2 CEU?s by October 12 or her job will be compromised. The A.D.S. Director will monitor the CEU notebook. Staff #4 finished her CEU requirements on 9/25/2019. Staff #1,3 & 4 inadvertently did not recall at the time of the inspection that a 4-hour in-service training took place on March 1,2019. The certificates are now in the CEU binder. The A.D.S. Director will monitor the CEU notebook.
Standard #:	22VAC40-60-570-B-1
Description:	Based on observation, record review, and interview, the center failed to ensure the plan of care include a description of the participant's needs. Evidence: 1. During the inspection, participant #3 was observed using a wheelchair. In addition, the participant's Uniform Assessment Instrument (UAI) dated 6-4-19 indicated the participant needs physical assistance with wheeling. During review of participant #3's record, the care plan dated 7-3-19, did not include a description of the participant's need for a wheelchair. 2. Staff #1 acknowledged participant #2's need for a wheelchair for ambulating while at the center.
Plan of Correction:	Staff #1 corrected the care plan for participant # 3 on 9/13/2019. Participant #2 does not use a wheelchair for ambulating. He uses a walker at home and at the Center. Staff # 1 said it was participant #1 that she acknowledged needing a wheelchair for ambulating at the center. Staff #1 corrected the care plan for participant # 1 on 9/13/2019.
Standard #:	22VAC40-60-600-B-4
Description:	Based on record review and interview, the center failed to ensure the admission physical examination report include a statement that the individual is or is not capable of administering his own medications without assistance. Evidence: 1. During participant record review, participant #1's admission physical exam dated 8-10-19 did not have a response to the statement regarding the participant's ability to administer their own medications with or without assistance. 2. Participant # 4's admission physical exam dated 7-29-19 was missing the statement regarding the participant's ability to administer medications with or without assistance. The physical exam did not address this elsewhere. 3. During interview, staff #1 acknowledged the information was not documented on the physical exam for the aforementioned participants.
Plan of Correction:	1. Staff #1 corrected participant #3?s admission physical exam on 9/13/2019. 2. Staff #1 corrected participant #4?s admission physical exam on 9/13/2019. 3. Staff #1 corrected all the admission physical exams of all of the participant?s on 9/13/2019. She also revised the Admission Physical Exam Form on 9/13/2019.