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: Sept. 3, 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

Technical Assistance:

Inspector reminded director of license application has not been received and should be completed as soon as possible as license expires 09/18/2021.

Comments:

A renewal inspection was initiated on 09-03-2021 and concluded on 09-13-2021. The director was contacted by telephone to initiate the inspection. The director reported that the current census was 35. The inspector emailed the director a list of items required to complete the remote documentation review portion of the inspection. The inspector reviewed 3 resident records, 3 staff records, staff schedule, activity calendar, fire and emergency drills, and menus submitted by the facility to ensure documentation was complete. Two inspectors conducted the on-site portion of the inspection on 09-02-2021. An exit interview was conducted with the Site Director on the date of inspection, where findings were reviewed and an opportunity was given for questions, as well as for providing any information or documentation which was not available during the inspection. Information gathered during the inspection determined non-compliance(s) with applicable standards or law, and violations were documented on the violation notice issued to the facility.

Violations:

Standard #:	22VAC40-61-300-E-7-d
Description:	Based on record review and discussion the facility failed to ensure documentation shall be maintained on the MAR of all medications, including prescription, nonprescription, and sample medication, administered to a participant while at the center. Evidence: 1. During review of the MAR for Participant #1 and Participant #3, the MAR did not include the time the medication was given. On the MARs reviewed, ?morning? is the time notated. 2. During interview on 09-10-2021, Staff #3 and Staff #7 acknowledged the time medication is given is not specifically noted on the MAR.
Plan of Correction:	Medication nurse will work with participant's provider to have time of day added to dosing instructions. After information is updated in the electronic medical record, medication nurse will update paper MAR.
Standard #:	22VAC40-61-360-B
Description:	Based on observation and documentation review, the facility failed to ensure menus for meals and snacks for the current week are dated and posted in an area conspicuous to participants. Evidence: 1. On 09-02-2021, during an inspection of the facility with Staff #1 and Staff #2, the Licensing Inspectors observed the menus for meals and snacks for the current week posted in the large dayroom. The posted menu did not specify the month and was dated the 15th to the 21st. Additionally, the snack schedule posted was dated for September 2020 to June 2021. 2. During interview on 09-02-2021, Staff #1 and Staff #2 acknowledged the date on the posted menu for both meals and snacks were not current.
Plan of Correction:	All menus have had months and numerical dates added to postings. Standing snack menu has had month and numerical dates added. Both menus will have month names and numerical dates added ongoing. Corrected during inspection.
Standard #:	22VAC40-61-530-B
Description:	Based on observation and documentation review, the facility failed to ensure the fire and emergency evacuation drawing included areas of refuge and assembly areas. Evidence: 1. On 09-02-2021, during an inspection of the facility with staff #1, the Licensing Inspector observed the fire and emergency evacuation drawings that were posted inside the clinic as well as outside the clinic in the large dayroom. The evacuation drawings did not include the area of refuge or the assembly area.
Plan of Correction:	Site director is working with the local fire marshal to determine if the terms "area of refuge" or "assembly area" apply to the facility (a one story building). Once this determination is made, the site director will updated the evacuation drawings as instructed.
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. During record review, there were no fire and emergency evacuation drills conducted nor documented in August 2021. 2. During interview on 09-08-2021, Staff #3 stated a fire and emergency evacuation drill was completed on 09-03-2021.
Plan of Correction:	The "August 2021" fire drill was completed the last day of the business week in August, rather than the last day of the calendar month. All drills will be completed prior to the end of the calendar month.