VIRGINIA DEPARTMENT OF SOCIAL SERVICES

Primeplus at M.E. Cox , Operated by Primeplus Senior Centers
644 North Lynnhaven Road
Virginia beach, VA 23452
(757) 625-5857

Current Inspector: Margaret T Pittman (757) 641-0984

Inspection Date: Jan. 20, 2022

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 22VAC40-90 The Criminal History Record Report

Comments:

An unannounced monitoring inspection by two Licensing Inspector was conducted on 1/20/22 from 9:38 a.m. until 12:59 p.m. and concluded 1/25/22. There were eight participants present. 21 participants are enrolled. Four staff were observed upon initial tour of the center. Four participant records and three staff records were reviewed. Two new staff had been hired since the last inspection. All participants were observed enjoying and participating in a range of activities. A morning snack and lunch were observed. The first aid kit was reviewed. One medication pass was observed while on-site. Additional information obtained 1/24/22 and 1/25/22.

Violations:

Standard #:	22VAC40-61-50-D
Description:	Based on observation and interview, the center failed to ensure the Adult Protective Services toll-free telephone number and the toll-free telephone number of the disAbility Law Center of Virginia are posted. Evidence: 1. On 01-20-2022, during a tour of the center with Staff #2, there was not a posting in the center that included the Adult Protective Services toll-free telephone number or the toll-free telephone number of the disAbility Law Center of Virginia. 2. Staff #2 acknowledged the two required numbers were not posted in the center.
Plan of Correction:	The Adult Protective Services toll-free telephone number and the toll-free telephone number for the Disability Law Center of Virginia were posted in the Center after the on-site inspection that was conducted on 01/20/2022. They were posted in the entry way of the Center as well as in the staff Break room on 01/25/2022.
Standard #:	22VAC40-61-160-A-1
Description:	Based on record review and interview, the center failed to ensure each direct care staff member maintain current certification in first aid. Evidence: 1. Staff #3, Staff #4, and Staff #5 work as Personal Care Attendants/Activity Assistants. Staff #1 was unable to provide a current certification in first aid for Staff #3, Staff #4, and Staff #5.
Plan of Correction:	Staff #3, Staff #4, and Staff #5 have all been enrolled in a CPR/First Aid class to be held on February 9, 2022.
Standard #:	22VAC40-61-180-E-1
Description:	Based on record review and interview, the facility failed to ensure each staff person obtain an evaluation by a qualified licensed practitioner that completes an assessment for tuberculosis in a communicable form no earlier than 30 days before or no later than seven days after employment or contact with participants. Evidence: 1. Staff #1 provided documentation of a chest x-ray for Staff #3 (date of hire 10-25-2021) completed on 03-15-2019. The documentation does not indicate whether or not Staff #3 is free from TB in a communicable form.
Plan of Correction:	Staff # 3?s Dr.?s office was called on 2/2/2022 requesting the TB form from the VA DSS website be completed. Going forward, the Center will make sure that any staff needing a chest X-Ray will be accompanied by the TB Form that is on the DSS website.
Standard #:	22VAC40-61-230-D
Description:	Based on observation, record review, and interview, the center failed to ensure the activities and services identified on the participant?s plan of care will be provided to meet their outcomes or goals. Evidence: 1. On 01-21-2022, during a tour of the center with Staff #2, a stall shower was observed; however, the shower room is currently utilized for center storage. 2. The Plan of Care for Participant #4 states the center will provide bathing assistance if needed; however, the center does not have the space set up to deliver this service. 3. Staff #2 acknowledged the shower room is currently utilized for storage and not accessible to provide bathing assistance if needed.
Plan of Correction:	The Plan of Care for Participant #4 states the center will provide bathing assistance if needed. The shower room was being utilized for storage and not accessible to provide bathing services. The shower room has been cleared out and the space is free of rubbish and safety hazards.
Standard #:	22VAC40-61-410-A
Description:	Based on observation, the center failed to ensure the interior and exterior of all buildings are maintained in good repair, kept clean and free of rubbish, and free from safety hazards. Evidence: 1. On 01-21-2022, during a tour of the center with Staff #2, a tile in the ceiling of the women?s restroom had a brown stain. The tile was next to a light fixture and was directly above one of the sinks in the restroom. 2. Staff #2 acknowledged the tile and stated it would be replaced.
Plan of Correction:	The ceiling tile in the women?s restroom that had a brown stain on it has been replaced. The tile was replaced it on 1/27/2022.
Standard #:	22VAC40-90-40-B
Description:	Based on record review and interview, the facility failed to obtain a criminal history record report on or prior to the 30th day of employment for each employee. Evidence: 1. Staff #1 provided a list of newly hired staff and dates of hire to include Staff #3 (date of hire 10-25-2021) and Staff #4 (date of hire 10-25-2021). 2. Staff #3 and Staff #4?s criminal history record report were requested by the Virginia State Police; however, the completed report has yet to be received by the facility. Staff #1 could not provide a completed criminal history record report for the aforementioned staff.
Plan of Correction:	The Adult Day Director called the VA State Police office on 1/25/2022 to see if they had received the original forms mailed on 10/25/2021. Their records showed the reports as pending but the original forms weren?t in their files. Staff # 3 and Staff #4?s criminal history record reports were remailed to the Virginia State Police Office on 1/26/2022. Status is still pending. Staff #3 and Staff #4 will be under supervision until the Background Checks are returned to the Adult Day Director.