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: March 11, 2020

Complaint Related: No

Areas Reviewed:

22VAC40-61 PROGRAMS AND SERVICES

Comments:

An unannounced monitoring inspection was conducted by a Licensing Representative on March 11, 2020 from 9:22 a.m. ? 2:10 p.m. The Site Director was present throughout the inspection. There were 58 participants during the inspection. During the inspection, the following was observed: activities, meals, tour of the facility, medication cart, posted items, water temperatures checked, first aid kits from the facility and transport vehicle, annual inspections of Fire and Health, and emergency preparedness material and fire drills were reviewed. Participant and staff records were reviewed. The following was discussed: medication expiration dates. 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.

Violations:

Standard #:	22VAC40-61-330-G-4
Description:	Based on record review and interview, the facility failed to ensure if one activity was substituted for another, the change was noted on the schedule. Evidence: 1. During review of the schedule of activities for the months of November 2019 to March 2020, there were no substitutions documented on the activity calendars for the Large or Small day room. 2. Staff #1 confirmed that there had been substitutions of activities on some dates, but that the changes were not documented on the schedules for the Large or Small day room, as they are posted on the day room calendar, and copies are not retained.
Plan of Correction:	Large dayroom calendars and copies were updated prior to inspector leaving for the visit. Recreation team members were re-trained on the expectation that substitutions must be noted on both the large, wall calendar and the copies maintained for records.