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: April 27, 2021 and April 28, 2021

Complaint Related: No

Areas Reviewed:

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

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 monitoring inspection was initiated on 4/27/21 and concluded on 4/28/21. The director or in-charge person was contacted by telephone to initiate the inspection. There were 20 participants present and 17 staff. The inspector emailed the director/person in charge a list of items required to complete the inspection. The inspector reviewed 3 participant?s records and 3 staff records submitted by the facility to ensure documentation was complete. Information gathered during the inspection determined non-compliance with applicable standards or law and a violation was documented 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 #:	22VAC40-61-540-A
Description:	Based on record review and discussion the facility failed to conduct fire and emergency evacuation drill frequency and participation in accordance with the current edition of the Virginia Statewide Fire Prevention Code (13VAC5-51). Evidence: 1. The last documented fire and emergency evacuation drill was conducted on 3/22/21 @2:32pm. 2. There were no fire and emergency evacuation drills conducted nor documented in January 2021 and February 2021. Staff #4 could not provide documentation indication the drills were conducted. 3. Staff #4 acknowledged there were no fire and emergency evacuation drills conducted at the facility in January 2021 and February 2021.
Plan of Correction:	The Sentara PACE site did not conduct fire drills during the months of December 2020, January, and February 2021 due to increased levels of COVID-19 infections in the area in an effort to prevent congregating in an area where 6 feet of distance many not be able to be maintained. Previously, internal policy was to conduct fire drills no less than quarterly. Upon further review with input from the local Fire Marshall's office, the policy has been changed to conduct drills monthly. Change will be effective May 2021. Staff will be re-trained on the updated policy change.