VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Sentara PACE - Churchland
5788 Churchland Boulevard
Portsmouth, VA 23703
(757) 392-2650

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

Inspection Date: Oct. 28, 2019

Complaint Related: No

Areas Reviewed:

22VAC40-60 PERSONNEL. 22VAC40-60 PROGRAMS AND SERVICES.

Comments:

Two Licensing Representatives conducted an unannounced monitoring inspection on October 28, 2019 from 1:22 p.m. to 4:31 p.m. There were 56 participants in care. The Director of Nursing, Activities Director, Social Services Director, and Clinical Dietitian were present during the inspection. The following was discussed: collections of water temperatures, and staff tuberculosis records filed at corporate office and the need to be onsite. Please submit your ?plan of correction? and ?date to be corrected? for each violation cited on the violation notice and return it within 10 calendar days. The plan of correction must indicate how the violation will be or has been corrected. The plan of correction must include: 1. Step(s) to correct the noncompliance with the standard(s) 2. Measures to prevent reoccurrence 3. Person(s) responsible for implementing each step and/or monitoring any preventative measures. If you have any questions, please contact your inspector Alexandra Poulter at 757-613-5133 or alexandra.poulter@dss.virginia.gov.

Violations:

Standard #:	22VAC40-60-235-C-1
Description:	Based on record review and interview, the facility failed to ensure that initial tuberculosis examination and reports and subsequent annual evaluations for tuberculosis were maintained at the facility for each staff member. Evidence: 1. The following staff members? records did not contain an initial tuberculosis examination and report or a subsequent evaluation for tuberculosis on 10-28-19: a. Staff #2?s date of hire was 11-09-92, and the last evaluation for tuberculosis was dated 03-30-17; b. Staff #5?s date of hire was 01-22-18, and the last evaluation for tuberculosis was dated 05-08-18; c. Staff #6?s date of hire was 10-03-12, and the last evaluation for tuberculosis was dated 08-21-13; and d. Staff #7?s date of hire was 08-19-19 and did not contain an initial tuberculosis examination and report. 2. Staff #3 observed and confirmed the aforementioned information was not maintained at the facility during inspection.
Plan of Correction:	Site Director will ensure that all tuberculosis examinations and reports will be made available to DSS Licensing Inspector at the time of the inspection. All requested TB reports as listed in the ?Description of Violation? column are attached to POC email. 1a ? Staff member will obtain TB screening at the next available occupational health appointment. 1c -- Staff member will obtain TB screening at the next available occupational health appointment. Moving forward, monthly monitoring of TB Screening/testing compliance will be completed for all staff members.
Standard #:	22VAC40-60-700-F-4
Description:	Based on observation and interview, the facility failed to ensure that if one activity was substituted for another, the change was noted on the schedule. 1. The activities calendar posted in the large dayroom on 10-28-19 documented between 12:45 p.m. ? 2:00 p.m., the activity was ?Halloween Hangman.? 2. Inquired with staff #2 regarding what activity was taking place on 10-28-19 between 12:45 p.m. ? 2:00 p.m., and staff #2 identified the activity as ?PACE Store.? 3. Staff #2 observed and confirmed the substitution and change of activity was not noted on the schedule.
Plan of Correction:	Re-educated all recreation staff members on requirement to update main activity calendar if changes are made. Update to the main activity calendar was made prior to the end of the inspection.
Standard #:	22VAC40-60-860-A
Description:	Based on observation and interview, the center failed to ensure a menu listing all meals and snacks to be served by the center during the current one-week period was dated and posted in a location conspicuous to participants and responsible persons. Evidence: 1. The menu posted in the large dayroom did not document snacks. 2. Staff #1 observed and confirmed the posted menu did not document snacks.
Plan of Correction:	1. A listing the daily snack has been posted in the main dayroom along with AM Snack/Lunch menu.