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: May 9, 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 GROUND 22VAC40-61 EMERGENCY PREPAREDNESS 22VAC40-80 THE LICENSE 22VAC40-90 BACKGROUND CHECKS FOR ASSISTED LIVING FACILITIES 22VAC40-90 THE SWORN STATEMENT OR AFFIRMATION 22VAC40-90 THE CRIMINAL HISTORY RECORD REPORT

Comments:

Type of inspection: Monitoring Date(s) of inspection and time the licensing inspector was on-site at the facility for each day of the inspection: 05/09/2022 from 8:30 am to 2:53 pm. The Acknowledgement of Inspection form was signed and left at the facility for each date of the inspection. Number of participants present at the facility at the beginning of the inspection: 0 The licensing inspector completed a tour of the physical plant that included the building and grounds of the facility. Number of participant records reviewed: 7 Number of staff records reviewed: 4 Observations by licensing inspector: Required postings and medication pass An exit meeting will be conducted to review the inspection findings. The evidence gathered during the inspection determined non-compliance with applicable standard(s) or law, and violation(s) were documented on the violation notice issued to the facility. The licensee has the opportunity to submit a plan of correction to indicate how the cited violation(s) will be addressed in order to return the facility to compliance and maintain future compliance with applicable standard(s) or law. If the licensee wishes to provide a plan of correction: (i) type the plan on a separate Word document, (ii) identify the standard violation number being addressed, (iii) include the date the violation will be corrected, (IV) do not include any names or confidential information, and (V) return to the licensing inspector by email within five (5) business days of the exit interview. Compliance with all applicable regulations and law shall be maintained and any areas of noncompliance must be corrected. Within 15 calendar days of your receipt of the inspection findings (inspection summary, violation notice, and supplemental information), you may request a review and discussion of these findings with the inspector's immediate supervisor. To make a request for review and discussion, you must contact the licensing supervisor at the regional licensing office that serves your geographical area. Regardless of whether a supervisory review has been requested, the results of the inspection will be posted to the DSS public website within 5 business days of your receipt of the Inspection Summary and/ or Violation Notice. The department's inspection findings are subject to public disclosure. Please Note: A copy of the findings of the most recent inspection are required to be posted on the premises of the facility. For more information about the VDSS Licensing Programs, please visit: www.dss.virginia.gov Should you have any questions, please contact M. Tess Pittman, Licensing Inspector at (757) 641-0984 or by email at tess.pittman@dss.virginia.gov.

Violations:

Standard #:	22VAC40-61-50-E
Description:	Based on record review, the center failed to review the rights and responsibilities of participants annually with each participant, or, if a participant is unable to fully understand and exercise his rights and responsibilities, the annual review shall include his family member or his legal representative. Evidence of this review shall include the date of the review and the signature of the participant, family member, or legal representative and shall be included in the participant's file. Evidence: 1. Resident #4, Resident #5, and Resident #6 did not have evidence of a review of rights and responsibilities of participants in their participant?s file.
Plan of Correction:	Rights and responsibilities are reviewed two times annually with all participants and caregivers. The center?s current process does not include obtaining a signature for this specific review, but does document in the participant?s electronic medical record review of the rights and responsibilities. The center will add a signature component to this review at each semi-annual assessment.
Standard #:	22VAC40-61-230-D
Description:	Based on record review, the facility failed to ensure the plan of care included descriptions of identified needs, dates identified, expected outcomes or goals, activities and services and dates of outcomes or goal achieved. Evidence: 1. The assessment for Participant #1 dated 3/25/22 indicates the participant requires mechanical assistance and supervision with eating; however, the plan of care dated 4/20/22 indicates the participant only requires supervision with eating. The assessment also indicates the participant is disoriented to some spheres sometimes; however, the plan of care indicates the participant is ?oriented to persons, places, times, and situations during all times.? 2. The assessment for Participant #2 dated 3/30/22 indicates the participant needs mechanical assistance and supervision with transfers; however, the plan of care dated 4/20/22 indicates the participant requires only supervision with transfers. The assessment also indicates the participant is disoriented to some spheres sometimes; however, the plan of care indicates the participant is ?oriented to persons, places, times, and situations during all times.? 3. The assessment for Participant #3 dated 3/1/22 indicates the participant is oriented; however, the plan of care dated 3/10/22 indicates the participant is ?disoriented to places and situations during some times.? The assessment also indicates the participant requires physical assistance with bathing and is continent of bowel; however, the plan of care indicates the participant requires physical and mechanical assistance with bathing and is incontinent with bowel less than weekly. 4. The assessment for Participant #4 dated 12/2/21 indicates the participant needs physical assistance with dressing, toileting, and eating; however, the plan of care dated 12/10/21 indicates the participant requires supervision with dressing, toileting, and eating. The assessment also indicates the participant requires mechanical and physical assistance with bathing; however, the plan of care indicates the participant requires only supervision with bathing. The assessment indicates the participant is incontinent of bowel less than weekly; however, the plan of care indicates the participant is incontinent of bowel more than weekly. Lastly, the assessment indicates the participant does require assistance with medication administration; however, the plan of care indicates the participant does not require assistance with medication administration. 5. The assessment for Participant #5 dated 12/10/21 indicates bathing, dressing, and eating is performed by others for the participant; however, the plan of care dated 12/15/21 indicates the participant needs physical assistance with bathing, dressing, and eating. The assessment also indicates the participant requires physical assistance with transfers; however, the plan of care indicates the participant needs supervision with transferring.
Plan of Correction:	Moving forward, the center will ensure the two nursing assessments that comprise the care plan and 99p documents match prior to finalization of the care plan.
Standard #:	22VAC40-61-240-A
Description:	Based on record review, the facility failed to ensure at or prior to the time of admission, there be a written agreement between the participant and the center. The agreement shall be signed and dated by the participant or legal representative and the center representative. Evidence: 1. While reviewing participant records with Staff #7, the written agreement between Participant #4 and the center indicates a verbal agreement was made with the participant on 6/30/21. Participant #4 admitted on 7/1/21 and has a diagnosis of progressive dementia.
Plan of Correction:	The center will ensure admissions team members are made aware if the participant cannot/should not sign the enrollment agreement based on intake assessment.
Standard #:	22VAC40-61-300-E-7-d
Description:	Based on record review, observation, and discussion, the facility failed to ensure documentation 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 the medication pass observation, Staff #6 indicated there was not a MAR to maintain or document the medications administered to participants at the center. The system is currently being worked on as the center began offering medication administration as of 05-02-2022 per Staff #6 and Staff #1. Staff #6 administers medications based off the current orders in the electronic medication record. At this time, Staff #6 documents in a nurses note that medications are administered; however, it does not indicate the diagnosis, drug product name, dosage and strength of medication, or route of administration. For example on 05-09-2022, after administration of medications for Participant #8, Staff #6 wrote ?Patient took medications as directed without difficulty.? Participant #8 and Participant #9 were administered medications on 05-09-2022.
Plan of Correction:	An electronic MAR is being developed for the center. In the interim, the center will utilize a paper MAR for medications passed at the day center.