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 4, 2022

Complaint Related: No

Areas Reviewed:

22VAC40-61 PERSONNEL 22VAC40-61 BUILDINGS AND GROUNDS

Comments:

An unannounced monitoring inspection was conducted on 03-04-2022 by two Licensing Inspectors from 8:20 a.m. until 1:51 p.m. Upon arrival, there was 1 participant in care with an additional of 25 scheduled to come throughout the day. Participants were observed being engaged in exercise during the inspection. Five participants and three staff records were reviewed. There were three new staff members hired since the last inspection. There are no participants receiving medication at this time, therefore medication administration was not observed. The menu, activity calendar, fire drill records, health and fire inspection, building and vehicle first aid kits, and water temperature were reviewed. 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. The areas of noncompliance were discussed with the Administrator throughout the inspection and during the exit interview.

Violations:

Standard #:	22VAC40-61-180-E-2
Description:	Based on record review, the center failed to ensure all staff and volunteers have an annual tuberculosis risk assessment completed. Evidence: 1. Staff #2 did not have a current annual evaluation for tuberculosis (TB). The last TB evaluation for Staff #2 is 02-03-2021. 2. Staff #1 acknowledged the TB evaluation for Staff #2 is not current.
Plan of Correction:	The missing annual risk assessment for staff member #2 has been completed.
Standard #:	22VAC40-61-410-A
Description:	Based on observation, the center failed to ensure the interior and exterior of all buildings be maintained in good repair, kept clean and free of rubbish, and free from safety hazards. Evidence: 1. On 03-04-2022, while conducting the inspection at the center, the fence in the outdoor courtyard to the touch was not secure. 2. Staff #1 acknowledged the concern regarding the stability of the outdoor fence.
Plan of Correction:	The exterior fence has been inspected by facility maintenance team member. Maintenance is working on a repair/replacement plan. While the center awaits repairs/replacement, the patio will not be in use.
Standard #:	22VAC40-61-460-I
Description:	Based on observation, the center failed to ensure disposable gloves are in each restroom at all times. Evidence: 1. On 03-04-2022, while conducting the inspection at the center, the two single use restrooms in the large dayroom were observed being utilized by participants and did not have disposable gloves available.
Plan of Correction:	Glove stock was replenished immediately. Checking stock of supplies in the participant bathrooms has been added to the aide?s responsibilities at the end of each day.