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: Jan. 13, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-61 GENERAL PROVISIONS 22VAC40-61 ADMINISTRATION 22VAC40-61 PERSONNEL 22VAC40-61 SUPERVISION 22VAC40-61 ADMISSION, RETENTION, AND DISCHARGE 22VAC40-61 PROGRAMS AND SERVICES 22VAC40-61 BUILDINGS AND GROUNDS 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE. 22VAC40-90 The Criminal History Record Report

Technical Assistance:

The center staff were made aware of the crosswalk tool between the old and new regulations on the website. Staff were reminded of the upcoming training on 2-6-2020 Please submit the renewal application before your license expires in March 2020.

Comments:

An unannounced renewal inspection was conducted on this date from 11:35 a.m until 3:32 p.m. Five participants and four staff were present. One of the five participants present had been admitted since the last inspection. Four participant records and three staff records were reviewed. No new staff had been hired. The posted morning activity of cards and the afternoon activity dominoes was observed. All participants were engaged. The posted lunch received from the catered kitchen of hot dogs, baked beans,chips,and tea was observed. No medications are administered . The inspector cross walked the old and new regulations with the center director . The staff plans to send copies of new forms. The health inspection of the catered kitchen was requested. The staff was advised to get written approval from the fire official to use the space observed in the day room. Multiple flannel throws were observed available for the participants use. 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 1-25-20 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 #:	22VAC40-61-180-E-2
Description:	Based on record review and interview the facility failed to ensure one of three staff employed over a year had a subsequent evaluation for tuberculosis. Evidence 1. While reviewing staff records with staff #3, the inspector found staff #1, last TB evaluation on file was dated 11-21-18. 2. Staff #3 confirmed that was the last TB report found on file .
Plan of Correction:	Tina's World of Love will keep a spread sheet of all employees' required TB evaluations to ensure that all employees have a current TB screening on file. Staff #1 is now current with a TB screening
Standard #:	22VAC40-61-220-E
Description:	Based on record review and interview the facility failed to ensure an assessment was reviewed and updated at least every six months. Evidence 1. While reviewing the participant files with staff #3, the inspector found one of two participants in care over six months did not have an assessment reviewed and updated at least every six months. 2. Participant #2's admitted 5-6-19, last assessment on file was dated 4-25-19 . 3. Staff #3 searched the file and confirmed at the time of this inspection the 4-25-19, assessment was the only one located on file.
Plan of Correction:	Tina's World of Love will keep a spread sheet of all participants scheduled assessments to ensure assessments are updated at least every six months. All participants' assessments are currently up to date.
Standard #:	22VAC40-61-260-B
Description:	Based on record review and interview the facility failed to ensure a new participant's required physical examination report on file at the center included the following : any known allergies and description of the person's reactions; any therapy, treatments, or procedures the individual was undergoing or should receive and by whom; a statement that specified whether the individual was or was not capable of self-administering medication;a statement that specified whether the individual was or was not capable of self-.administering medication; any special diet or any food intolerances; any restrictions or limitations on physical activities or program participation; or a statement that specified whether the individual was considered to be ambulatory or nonambulatory; Evidence 1. While reviewing the new participants file with staff #3 , the inspector found participant #1 admitted 11-18-19 ,had a doctor's office visit summary on file that did not contain all the require health information. It did not include any known allergies and description of the person's reactions; any therapy, treatments, or procedures the individual was undergoing or should receive and by whom; a statement that specified whether the individual was or was not capable of self-administering medication;a statement that specified whether the individual was or was not capable of self-.administering medication; any special diet or any food intolerances; any restrictions or limitations on physical activities or program participation; or a statement that specified whether the individual was considered to be ambulatory or non-ambulatory. 2. Staff #3 confirmed the doctor's office visit summary did not contain all the required health information.
Plan of Correction:	Tina's World of Love will make sure we only accept the report of participants physical examination form number 032-05-073 for all new participants.. This will ensure that we have all the required information needed to make sure a participant is eligible for admittance into the program.
Standard #:	22VAC40-61-410-A
Description:	Based on observation and discussion the facility failed to ensure the interior of the buildings was maintained in good repair. Evidence 1. While with staff #3 in the dining room area of the center , the inspector observed two brown stain ceiling tiles. 2. Staff #3 stated "some residual leaking, subsequent to the roof repair and other tile replacement, must have caused the discoloration in the tiles" .
Plan of Correction:	The owner of the building was contacted and informed about the roof leaking. He said he would have someone out this week to take a look at the roof. The soiled tiles has been replaced. Management will keep in touch with the owner to make sure the roof is sealed properly. .
Standard #:	22VAC40-61-550-A
Description:	Based on observation and discussion the facility failed to ensure the center a complete first aid kit which included the following: Antibacterial ointment and bee sting swab or preparation. Evidence 1. While checking the first aid kit with staff #3 and #4 , the inspector observed no ointment or bee sting preparation in the first aid kit . 2. Staff #3, confirmed at the time of the inspection, the ointment and the bee sting preparation were not in the first aid kit.
Plan of Correction:	The first aid kit has been restocked with all the items required. Bee sting ointment has been difficult to find, agency has purchased sting relief swabs, insect sting relief ointment for the first kit as well as the Antibacterial ointment. Staff has been designated to be responsible for making sure first aid is up to date.