VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Riverside Adult Day Services Center-Denbigh
1010 Old Denbigh Blvd.
Newport news, VA 23602
(757) 875-2033

Current Inspector: Darunda Flint (757) 807-9731

Inspection Date: July 1, 2020 , July 6, 2020 , July 7, 2020 , July 8, 2020 and July 16, 2020

Complaint Related: No

Areas Reviewed:

Part III- Personnel Part V- Admission, Retention and Discharge Part VIII- Emergency Preparedness 63.2 Protection of adults and reporting. 63.2 Licensure and Registration Procedures 22VAC40-90 Background Checks for Assisted Living Facilities 22VAC40-90 The Sworn Statement or Affirmation 22VAC40-90 The Criminal History Record Report

Comments:

This inspection was conducted by licensing staff using an alternate remote protocol, necessary due to a state of emergency health pandemic declared by the Governor of Virginia. A renewal inspection was initiated on 7-1-20 and concluded on 7-16-20. The director or in-charge person was contacted by telephone to initiate the inspection. There were 10 participants present and 3 staff. The inspector emailed the director/person in charge a list of items required to complete the inspection. The Inspector reviewed two participant's records and two staff records submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliances with applicable standards or law and violations were determined on the violation notice issued to the facility. The Licensing Inspector has reviewed with the director/person in charge COVID-19 guidance posted on the ADCC webpage.

Violations:

Standard #:	22VAC40-61-150-A
Description:	Based on record review and staff interview, the facility failed to ensure one of two staff who provide direct care to participants shall attend at least 12 hours of training annually. Evidence: 1. A review of staff #3?s record review during remote inspection indicated staff #3 record noted seven (7) hours of annual training. 2. On 7-15-20 a request for additional training information for staff #3 was requested from staff #1. A review of all training documents received noted seven (7) hours of annual training. Staff #3?s date of hire (doh) was noted as 2-20-18. 3. On 7-16-20 during the exit interview with staff #1 acknowledged staff #3?s record did not include the required number of hours of annual training.
Plan of Correction:	1. Staff #3 will receive the required 12 hours of training by the Director of Adult Day Care/designee through online modules or other in person opportunities. (10/18/20) 2. An audit of all staff training records will be completed by The Director of Adult Day Care/designee. (9/30/20) 3. The Riverside Educator will be contacted by The Director of Adult Day Care/designee to access required training opportunities for staff. The Director of Adult Day Care/designee will explore opportunities through DSS, Alzheimer?s Association and Leading Age to adhere to the adequate training hours for all staff. (10/18/20) 4. A monthly audit of 2 staff training records will be completed by The Director of Adult Day Care/designee for three months to ensure required hours are documented. 5. All items will be completed by October 18, 2020.
Standard #:	22VAC40-61-230-F
Description:	Based on record review and staff interview, the facility failed to ensure two of two participants plan on care (poc) was signed and dated by the participant, family member, or legal representative. Evidence: 1. During the remote renewal inspection, a review of participant #1's plan of care dated 2- 13-20 was not signed and dated by the participant, family member, or legal representative. Participant #1's date of admission noted as 2-13-20. 2. A review of participant #2's record noted the updated plan of care dated 2-28-20 was not signed by the participant, family member or legal representative. 3. Staff #1 acknowledged the plan of care for participant #1 and #2 were not signed by the participant, family member or representative during the exit interview on 7-16-20.
Plan of Correction:	Participant #1?s plan of care dated 2/13/20 will be reviewed and signed by family. Participant #2?s plan of care dated 2/28/20 will be reviewed and signed by family. (8/31/20) 2. All participant?s most recent plans of care will be reviewed by the Director of Adult Day Care/designee to ensure signatures are present. (9/30/20) 3. The Director of Adult Day Care/designee will develop a signature page to reflect signature by required party on initial and subsequent care plans. A procedure will be developed by the Director of Adult Day Care/designee on signatures for all current participant care plans.(7/24/20) 4. A monthly audit of care plans will be completed by the Director of Adult Day Care/designee for three months on 2 participants to ensure all required information has been completed 5. All items to be completed or a plan will be in place to complete by September 30, 2020.
Standard #:	22VAC40-61-260-B
Description:	Based on record review and staff interview, the facility failed to ensure one of two participants physical examination included all required information. Evidence: 1. During the remote inspection, a review of participant #1's physical examination noted the field address and telephone number was blank. 2. Staff #1 acknowledged the information was not included on the physical examination for participant #1 during the exit interview on 7-16-20.
Plan of Correction:	1. The missing information (address and phone number) on participant #1?s physical exam form will be requested to be added by the physician. (8/7/20) 2. All participant?s physical examination reports will be reviewed by the Director of Adult Day Care/designee to ensure required items are included. (8/31/20) 3. The admission checklist was updated to include verifications that all fields have been completed. (7/30/20) 4. A monthly audit of physical examination reports will be completed by the Director of Adult Day Care/designee for three months on 2 new participants to ensure all required information has been completed. 5. All items to be completed or a plan will be in place to complete by August 31, 2020.
Standard #:	22VAC40-61-540-E
Description:	Based on document review and staff interview, the facility failed to ensure the record of the fire and emergency evacuation drills included all of the required information. Evidence: 1. A review of the fire and emergency drills submitted for review during the remote renewal inspection did not include the following information: (a) time of drill, (b) method use for notification of the drill, (c) any special condition simulated and (d) weather condition. 2. Staff #1 acknowledged information not included on the fire and emergency drill form submitted for review.
Plan of Correction:	1.The Director of Adult Day Care/designee reviewed the required documentation needed on all fire drills. (7/24/20) 2. A review of the most recent emergency drills will be conducted by the Director of Adult Day Care/designee to ensure all required items are identified on the documentation of the drill. (7/24/20) 3. The current fire drill form will be revised by the Director of Adult Day Care/designee to include newly required pieces of information and implemented for the July Fire Drill. 4. The monthly drill will be reviewed by the Director of Adult Day Care/designee for three months to ensure all required items are documented. 5. All items to be completed or a plan will be in place to complete by July 24, 2020.